20 minute read
Keep Moving Toward Value Even with a Pause in N.C. Medicaid Transformation
By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President
~ ACADEMY IN ACTION ~
While the move to Medicaid managed care in North Carolina has temporarily hit the pause button, the march to value in our state and country continues. And this is a march that can benefit Family Medicine greatly, if we are prepared and harness the opportunity.
Today, more than ever, employers, payers and individual patients are all realizing the value that Family Medicine brings to the healthcare system.
Blue Cross and Blue Shield of NC is increasing payment to high quality independent primary care practices, holding health systems more accountable for the total cost of care, and partnering with other companies to assist primary care practices in meeting the quadruple aim.
Medicare, despite the bureaucratic nature of CMS, continues to experiment with ways to put primary care at the center of healthcare, including the Primary Care First Initiative which will be offered in parts of 26 states, even though it won’t yet be available in North Carolina.
Small and large employers alike are direct contracting with Direct Primary Care practices to provide much needed healthcare to their employers.
Primary care practice groups right here in North Carolina are working to use physician-led, team-based care along with technology to provide care closer to where patients live and in a more integrated manner.
The bottom line: many people are embracing the promise and value of Family Medicine, but we cannot rest on our laurels.
So how do we all continue to work together to capitalize on this potential promise. First and foremost, we don’t stop preparing – for value-based care or Medicaid managed care. Here are just a few steps you can consider taking over the next few months:
• Work to bring care management closer to your patients.
• Embrace technology to provide better care and shift administrative burden from physicians to other team members.
• Work to align any value-based incentives you may receive from any of your payers, whether it’s commercial insurance, Medicare Advantage plans or ultimately Medicaid managed care plans.
• If you work within a system, advocate for a better environment for Family Medicine. We have one-pagers and other information that can help you show your own system the value of primary care. (See sidebar)
• Continue to choose partners that can help enhance the care you deliver.
• Examine your own referral patterns to see if you are utilizing high-value, low cost specialists when referring most of your patients.
• Look for ways to identify care gaps and fill them in an efficient and effective manner.
•And finally, let the Academy know how we can help advocate for you no matter your practice situation. Today, we have better contacts with payers and health care systems than we have ever had before.
Advocacy One-Pagers for Family Medicine Download at www.ncafp.com/one-pagers
The Value of Family Medicine In simple, straightforward terms, describes FM’s value to patients, families and communities.
The Value of Family Medicine Critical For North Carolina to Improve Quality and Lower Costs Family physicians: Your trusted healthcare advisor, for life.
❏ Increased access to primary care leads to better health outcomes for patients. Where access to primary care is higher, death rates from cancer, heart disease, and strokes are lower. 1,2
❏ On average, adults who have a primary care physician have 33% lower health care costs. 3
❏ Increased primary care access reduces emergency room visits, hospitalizations, and surgeries. 4
❏ Increasing the number of primary care physicians in a state by 1 per 10,000 population, while holding constant the total number of physicians, is associated with a rise in the state’s quality rank of more than 10 places, as well as a reduction in overall Medicare spending of $684 per beneficiary. .5
❏ For each one percent increase in primary care physicians, average-sized metropolitan areas experienced a decrease of 503 hospital admissions, 2,968 emergency room visits and 512 surgeries. 6
❏ Increasing the percent of the healthcare dollar spent on primary care reduces overall healthcare costs and improves quality. For example, from 2008-2011, total primary care spend for commercial health insurance members in Rhode Island increased by 23 percent, resulting in a reduction of 18 percent for total medical spending. 7
❏ Both increasing the level of physician-patient continuity (i.e., the same primary care physician seeing the patient regularly over time) and increasing the comprehensiveness of care provided by a family physician (i.e., a broader spectrum of services) lead to lower healthcare costs and fewer hospitalizations. 8,9
The Ask: Invest more in family medicine in your healthcare systems. As we move to value, that action will increase quality and lower overall cost of care. Provide the needed resources to your primary care clinics as they continue to live in the two worlds of RVU compensation and value-based quality metrics. This could include the use of scribes, additional medical assistants, imbedded behavioral health services, etc.
Footnotes: 1 The Commonwealth Fund, “Health Reform & You – Primary Care: Our First Line of Defense.” 12 June 2013. 2 Macinko, J, B Starfield and L. Shi. “Quantifying the Health benefits of Primary Care Physician Supply in the United States.” International Journal of Health Services Research. 2007. Vol. 37, NO. 1:111-126). 3 Franks, P. and K. Fiscella. 1998. “Primary Care Physicians and Specialists as Personal Physicians. Health Care Expenditures and Mortality Experience.” Journal of Family Practice 47:105-9. 4 Rosenthal, T. “The Medical Home: The Growing Evidence to Support a New Approach to Primary Care.” Journal of the American Board of Family Medicine. September-October 2008. Vol 21. No. 5. 5 Baicker, Katherine and Chandra, Amitabh. “Medicare Spending, the Physician Workforce and Beneficiaries’ Quality of Care.” Health Affairs Web exclusive w4.184 (7 April 2004: 184-197). 6 Kravet, Steven J., et al. “Health Care Utilization and the Proportion of Primary Care Physicians.” Amer J Med 121.2 (2008): 142-148. 7 ”Primary Care Spending in Rhode Island.” Office of the Health Insurance Commissioner. September 2012. 8 A Bazemore et al. “Higher Primary Care Physician Continuity is Associated with Lower Costs and Hospitalizations.” Annals of Family Medicine. Vol. 16, No. 6, November/December 2018. 9 A Bazemore et. al. “More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations.” Annals of Family Medicine. Vol. 13, No. 3. May/June 2015.
The Scope of Family Medicine Describes the breadth of training that FPs complete, as well as their typical scope of patient care.
The Scope of Family Medicine Family physicians: Your trusted healthcare advisor, for life. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focusing on integrated care. In the increasingly fragmented world of healthcare, one thing remains constant: a continuous and comprehensive relationship between a patient and their family physician.
❏ Family physicians provide the majority of care for America’s underserved populations and are distributed more proportionally than any other specialty. 1
❏ As part of their three-years of residency, family physicians participate in integrated inpatient and outpatient learning in six major medical areas: pediatrics, obstetrics and gynecology, internal medicine, psychiatry and neurology, surgery and community medicine. 1,2
❏ Family physicians also receive instruction in many other areas during residency, including geriatrics, emergency medicine, ophthalmology, radiology, orthopedics, otolaryngology, and urology. 1,2
❏ Family physicians deliver a range of acute, chronic and preventive medical services while providing patients with a patient-centered medical home. 1
❏ Delivery-related outcomes between family physicians and obstetricians/gynecologists have been studied for four decades and have shown little or no difference in the outcomes of family physicians practicing obstetrics compared to Ob/Gyns in low risk pregnancies. 3
❏ A recent study went further comparing delivery-related complications without any risk adjustments and concluded that family physicians practicing obstetrics have comparable delivery related complications as Ob/Gyns when looking at 19 common delivery complications. 3
❏ Without the Family Physician workforce, the loss of access to maternity services in economically disadvantaged communities will likely widen the health disparities in the United States. 4
❏ In a 2017 survey of North Carolina family medicine residents, 73 percent of the respondents said they would either leave or at least strongly consider leaving the state if they could not find a position with their desired scope of practice. The Ask Consider how to provide your family physicians a broader scope of practice, including OB, if desired.
Footnotes: 1 A Description of the Specialty of Family Medicine, American Academy of Family Physicians, www.aafp.org. 2 Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine. 3 Avery, DM; Waits, Shelley, Parton, JM. “Comparison of Delivery-Related Complications Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics.” American Journal of Clinical Medicine, Winter, 2014. 4 Taylor, JT; Hartman, SG; Meunier, MR; Panchal, B; Pecci, CC; Zink, NM & Shields, SG. “Supporting Family Physician Maternity Care Providers.” Family Medicine. Vol. 50, No. 9, 662, October 2018
North Carolina’s Family Medicine Workforce Pipeline As the state’s largest specialty, ensuring a robust pipeline of future family physicians is a key goal.
The Family Medicine Workforce Pipeline Family physicians: Your trusted healthcare advisor, for life.
❏ Family medicine is by far the largest specialty in the state. Twenty-seven North Carolina counties do not have an Ob/Gyn, and 17 counties do not have a pediatrician. Only four counties lack a family physician. 1
❏ Family medicine is on the rise in our state. In 2018, over 15 percent of graduating medical students (92 of 597) in North Carolina chose family medicine as their specialty, compared to a national average of 9.4%. 2
❏ Early medical school exposure to primary care works. Over 57% of the participants in the NCAFP Family Medicine Scholars Program entered family medicine residencies, with 63% staying in state for residency. Nearly a third of medical students who participated in other NCAFP summer clinical experiences entered family medicine residencies between 2013 and 2017, with 65% staying in state for training. Bn comparison, during that same period only 10.7% of allopathic medical students in NC entered family medicine, and only 48% stayed in state. 3
The Ask Provide dedicated time and/or compensation for community-based primary care physicians who precept/teach health professions students during their clinical day. High-quality, engaged and satisfied role models make a difference in student choice of specialty. Invest in family medicine workforce and leadership development initiatives both in your system and externally.
Footnotes: 1 North Carolina Health Professions Data System, the Cecil G. Sheps Center for Health Services Research, University of North Carolina. 2 2018 Family Medicine Residency Match Results and Data from NC Medical Schools. 3 Results of the Family Medicine Scholars Initiative, A Joint Project of the NC Academy of Family Physicians Foundation and the Blue Cross and Blue Shield of NC Foundation.
Now, back to NC Medicaid Managed Care for just a few minutes. As you know, the NCAFP fought hard against bringing managed care to our state. And once the legislature moved this direction, we fought hard to keep the process as simple for practices as possible. And while we know things will not be perfect, there are some areas of Medicaid managed care that you may want to choose to embrace. For example:
The waiver to allow managed care in North Carolina is providing an opportunity for a renewed focus on social determinants of health. As a result, the state has developed the NCCare360 platform, which will ultimately provide a robust statewide resource directory to help address many of the social needs of your patient, including food insecurity, housing, transportation, and interpersonal violence. The program allows practices to electronically connect with community resources and close the feedback loop when someone in your office may need to refer a patient to social support services in your community.
The managed care plans will be covering an array of services that Medicaid does not cover today. For example, some plans are providing cash incentives for baby products, gift card rewards for wellness visits, membership in youth or fitness clubs, assistance with life skills training or even a voucher to help someone receive their GED. Others are providing additional services such as hearing aids, acupuncture or even free meal delivery after a hospital stay. These are all items that are not available to your patients under traditional Medicaid.
The new system will provide for “whole person care” without carve outs for behavioral health that have long caused confusion and administrative burden for both physicians and Medicaid recipients.
The new program design contains key policy and contract provisions that will require managed care companies to incentivize and reward primary care physicians for providing comprehensive, high quality care for their patients.
Yes, once Medicaid managed care begins to be implemented, there will be stumbling blocks, administrative issues and some problems. When there is a such a significant change for nearly 2 million patients in North Carolina, you can’t expect otherwise. But there are also some opportunities that can be seized as part of this transformation.
We don’t know when Medicaid managed care will be implemented, but it’s not a matter of if, it is a matter of when. So now is the time to prepare. Many of the things you do to prepare for Medicaid managed care now will help you with other value-based contracts as we move into the future.
NCAFP Sights & Scenes
By Peter Graber NCAFP Communications
NCAFP Members Receive Degree of Fellow Eight NCAFP members were formally recognized with the AAFP Degree of Fellow during this year’s Annual Meeting. They include: Elizabeth Baltaro, MD, FAAFP; Jewell P. Carr, MD, FAAFP; Christina M. Garcia, MD, FAAFP; Shivajirao P. Patil, MD, FAAFP; David E. Peltzer, MD, FAAFP; Anita M. Pisharody, MD, FAAFP; Robert E. Scott, MD, FAAFP; and Erika Steinbacher, MD, FAAFP.
2019 Community Teaching Award Honorees Several NCAFP members were recognized in December as Outstanding Community Teachers for their efforts to teach medical students in their practices. The honorees were: Benjamin S. Dieter, MD (The Brody School of Medicine at East Carolina University), Vance Family Medicine, Henderson; Andrea M. DeSantis, DO (University of North Carolina School of Medicine), North Park Clinic, Charlotte; Edward J. Bujold, MD (Wake Forest School of Medicine), Granite Falls Family Medical Care Center, Granite Falls; Ronnie J. Barrier, MD (Campbell University Jerry M. Wallace School of Osteopathic Medicine), Rowan Family Physicians, Salisbury; and Yvonne E. Berstler, MD (Duke University School of Medicine), Duke Primary Care, Butner-Creedmoor.
Dr. Tamieka Howell Appointed to AAFP Membership Commission Congratulations to NCAFP Past President Tamieka Howell, MD, (’18) on her recent appointment to the AAFP Commission on Membership and Member Services! The Commission is charged to manage the working tasks related to the mem
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Beating the Odds
Gaston Physician Named 2019 North Carolina Family Physician of the Year
Courage to face and conquer extreme personal challenges is the hallmark of North Carolina’s 2019 Family Physician of the Year – Dr. Aregai Girmay of Gaston Family Health Services. Dr. Girmay was recognized with the award last December during the NCAFP’s Winter Family Physicians Weekend in Asheville.
Along his journey to Family Medicine, Dr. Girmay overcame tremendous personal obstacles. At the age of 19, Girmay fled his home country of Ethiopia, walking alone on foot for several days into neighboring Sudan. He would spend roughly the next three years as a refugee there waiting to be adopted by an American relief agency.
But in the course of this struggle, Dr. Girmay had experiences that would change the course of his life. While a refugee, Girmay worked as a translator to a pediatrician and what he witnessed had a profound impact.
“I was able to witness the miracle of healing. I was inspired by his ability to take children from the brink of life and intervene in a way that immediately changed the course of their life,” Dr. Girmay noted.
When Girmay was finally rescued at the age of 22, he eventually landed in St. Louis with no money, no possessions and little to no knowledge of the English language. Undeterred, he went on to enroll at St. Louis University, graduating in just three short years with a chemistry degree. After graduation, he worked as a chemist, but the pull of serving others and the miracles of healing he had experienced as a younger man drew him elsewhere. He enrolled in medical school, attending the University of Illinois College of Medicine . Primary care was always on his mind.
“Overall, I was interested in primary care and thought that translated well to OB/GYN,” Girmay recalled. After graduation, he entered an obstetrics/gynecology residency. “But after a few years, I decided to pursue Family Medicine so that I could provide a wider scope of care to a breadth of patients.”
When he entered Family Medicine at St. Joseph Medical Center in Yonkers, New York, he immediately was struck by its culture.
“Throughout my Family Medicine residency, I was impressed with the pleasant personalities of many of the family physicians that I encountered, which left a lasting impression on me,” he recalled. “Medicine tends to attract very driven and focused individuals, and I was drawn to the field where the physicians seemed very laid back and personable.”
After completing residency, a combination of fate and luck brought him to North Carolina. Hooking up with the North Carolina Office of Rural Health and its loan repayment program, Dr. Girmay was placed at Gaston Family Health Services, a Federally qualified health center headquartered in Gastonia in 1997.
He continues in practice there today, serving all patients with his unique combination of OB training and Family Medicine. In serving many indigent patients, Dr. Girmay has been able to recognize and help tackle some significant issues surrounding care access.
“I have realized that there is a gap that exists for many women who either do not have insurance or their insurance does not cover private OB/GYN visits,” described Girmay. “I took it upon myself to treat women who do not have access to proper pre-cancer treatment that is often provided by private OB/GYNs.”
While Girmay’s focus remains on providing broadscope primary care to those in need, he has continually pursued his passion for women’s health, especially related to cervical cancer prevention. He oversees a
The Girmays (L to R) - Adina Girmay, Delina Girmay, Dr. Aregai Girmay, Zewdie Girmay, and Zachy Girmay. Not pictured, Ginet Girmay.
dysplasia clinic, as well as a colposcopy clinic, that provides vital clinical services to both insured and indigent populations of Gaston, Lincoln, Iredell, Catawba and Alexander counties. His work has helped move the needle and has saved lives.
Girmay also earned an HIV specialist certification as another component of his integrated care approach. He serves patients with HIV and sexually transmitted diseases, and he has had particular success with Hepatitis C. His efforts have been key in helping cure over 180 uninsured patients through Hepatitis C treatment in just the last 3 years. He delivers addiction services and has also obtained his DATA waiver to provide Medication Assisted Treatment to patients diagnosed with opioid-use disorder. Outside of practice, Dr. Girmay is an active member of several initiatives working to advance his local community. He has served as a member of the Highland Community Resource Center Board that provides several social services supports to residents of the Highland community in Gaston County, such as GED training, community advocacy, and more. Girmay is also active with the Physician Advisory Panel of Health Net Gaston and has participated in the treatment linkage committee of the Gaston Controlled Substances Coalition.
In his daily personal life, Dr. Girmay embraces healthy lifestyles in nearly everything. He believes personal responsibility is a driving factor.
“Personal responsibility is a major aspect of a person’s overall health because it allows for them to have a role in determining the outcome of their health,” described Girmay. “By choosing healthy options, such as a balanced diet, daily exercise, and self-compassion, people have the ability to alter the trajectory of their life.”
For Girmay, Family Medicine occupies a special place in helping patients in this journey, but leading by example is also critical. “Family physicians are one of the most continuous faces a patient sees, so by mirroring healthy choices themselves, they are setting an example of not only being able to advise patients, but also doing the work themselves.”
With that in mind, Dr. Girmay adheres to a rigorous fitness and exercise regimen in his daily life. Running occupies a central place.
“Personally, I found that daily exercise was a huge motivator for myself, my patients, and even my family. I find the time to run throughout the week as well as the weekends, serving as an example for my community and other professionals that these small choices make a big difference,” Girmay explained. Dr. Girmay has completed almost 70 marathons, including those in New York City and Boston.
Dr. Girmay’s career in Family Medicine and primary care has been blessed. Much of it, the result of his passion for caring and service.
And Dr. Girmay believes the community health center is an excellent option.
Dr. Girmay and his wife Zewdie have been married 30 years, and are the proud parents of 4 children: Zachy (UNC), 27, is a healthcare data analyst for GFHS; Genet, (UNC) 24, works in San Francisco’s tech industry; and Adina (UNC) and Delina (UNCW), 22, who both recently graduated this past year. bership and member constituencies. This includes working to further AAFP goals in membership recruitment, retention and services. Dr. Howell will be serving a four-year term.
Foundation Trustee Dr. Amy Marietta Highlighted in NC Medicaid Annual Report
North Carolina’s Medicaid and NC Health Choice programs released their 2018-2019 SFY annual report in late December. The report highlights the major accomplishments of the sprawling program and provides a series of snapshots on its impacts. NCAFP Foundation board member Dr. Amy Marietta, a family physician with Blue Ridge Community Health in Polk County, is highlighted for her work in providing full-spectrum care to Medicaid beneficiaries, especially related to prenatal care. Read the entire report at https:// files.nc.gov/ncdma/SFY2019-MedicaidAnnualReport-FINAL-20191220.pdf.
UNC’s Dr. Katrina Donahue Appointed to the U.S. Preventive Services Task Force
University of North Carolina at Chapel Hill Department of Family Medicine professor and vice chair of research, Katrina Donahue MD, MPH, has been appointed to the U.S. Preventive Services Task Force (Task Force) as one of its newest members. The Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. Members come from primary care and prevention-related fields, including Internal Medicine, Family Medicine, Pediatrics, behavioral health, Obstetrics/ Gynecology, and nursing. Members are appointed to serve a 4-year term.
Dr. Donahue is a professor and vice chair of research at the University of North Carolina at Chapel Hill department of family medicine. She is a family physician and senior research fellow at the Cecil G. Sheps Center for Health Services Research. She is also the co-director of the North Carolina Network Consortium, a meta-network of six practice-based research networks and four academic institutions in North Carolina. Dr. Donahue’s research areas of interest include practice redesign of health care delivery, chronic disease care and prevention, health behavior change, and collaborations among public health and primary care.
