2022 Legislative Session in Review

ADVOCACY

By Gregory K. Griggs, MPA, CAE

NCAFP Executive Vice President

~ Representing Family Medicine ~

The North Carolina General Assembly adjourned on July 1 with plans to return to conduct limited business once a month throughout the remainder of the year. During the 2022 Session, the NCAFP priorities included the following:

• Coverage expansion, particularly Medicaid expansion.

• Further monitoring the progress around implementing Medicaid Managed Care, including combining Health Choice and Medicaid into one program in the state.

• Preventing scope of practice incursions.

• Expanding support for the primary care pipeline in North Carolina.

• Working to decrease administrative burdens faced by practicing family physicians.

Coverage Expansion

The NCAFP remains committed to increasing health insurance coverage in the state. In 2022, for the first time ever, bills leading toward Medicaid expansion passed both chambers of the General Assembly, but with vastly different directions.

The Senate included wholesale changes in healthcare regulation as part of their expansion bill, including complete independent practice for all Advanced Practice Registered Nurses (APRNs), significant Certificate of Need reforms, Surprise Billing measures, a very insurance-friendly telehealth provision, and more. The House, on the other hand, passed more of a study bill, which would have directed the NC Department of Health and Human Services to begin expansion negotiations with the federal government. The House bill would have also required a subsequent vote in December after negotiations with the federal government had concluded. In the meantime, Governor Roy Cooper made Medicaid expansion his top policy priority.

Throughout the session, the NCAFP remained engaged with the House, the Senate, and the Governor, hoping for a compromise plan that could be passed this year. Efforts intensified late in the session, and on the last day, numerous proposals bounced back and forth between the two chambers and the Governor, but to no avail. However, there still may be a pathway toward expansion this year during one of the scheduled “mini sessions” the General Assembly plans to hold over the remainder of the year.

After signing the budget on July 11, Gov. Cooper noted that, “both the House and Senate now support it and both chambers have passed it. Negotiations are occurring now, and we are closer than ever to agreement on Medicaid expansion.” Senate Leader Phil Berger and House Speaker Tim Moore released a joint statement shortly after the Govern signed the budget, noting that they “are committed to working to improve healthcare access and expand Medicaid, while providing the necessary safeguards to preserve the state’s fiscal strength.”

Medicaid Transformation and the Merger of Health Choice and Medicaid

As you know, Medicaid Managed Care was implemented over the last year, with July 1, 2022, marking the first anniversary of the managed care program in North Carolina. However, certain special needs populations (including the Severely and Persistently Mentally Ill, the Intellectually and Developmentally Disabled, and others) numbering about 170,000 will enter what has been deemed “tailored plans” run by regional non-profit mental health agencies starting December 1, 2022.

One positive item that emerged in the state budget was the merger of the Health Choice program into Medicaid. Health Choice provides insurance for low-income children that do not qualify for Medicaid but cannot afford private insurance. While it covers many things, it does not include as many benefits as Medicaid. For example, it does not require EPSDT (Early and Periodic Screening, Diagnostic and Treatment) services. Prior to managed care, this difference was less problematic. However, now with five managed care plans, each of those plans also must deal with Health Choice a bit differently, meaning practices are really dealing with up to 10 sets of rules, and for only about 60,000 children receiving Health Choice benefits. The policy change in the state budget will allow all Health Choice recipients to receive Medicaid benefits without changing their eligibility requirements, effective July 1, 2023. This will simplify things greatly for practices, the state, and the managed care plans.

Scope of Practice

Scope of practice battles continued to dominate the policy landscape in North Carolina this year, with most of the focus being on Physician Assistants and APRNs.

Physician Assistants – Senate Bill 345 sought to provide some flexibility in Physician Assistant supervision and had been thoughtfully negotiated over the last few years through a “Medical Team Task Force” established by the NC Medical Society, which included significant input from the NCAFP, the NC Academy of Physician Assistants and many others. As a result, the NCAFP supported this bill. The bill would have eliminated the requirement of individual physician supervision IF, and only IF, the Physician Assistant met and maintained the following criteria: • 4,000 hours of post-graduate closely supervised training and more than 1,000

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• Practicing in a team-based setting.

In the bill, team-based practice was tightly defined to require a level of physician involvement and ongoing quality improvement efforts at the practice level. It also excluded pain management clinics and perioperative settings. In 2021, during the first year of the two-year legislative biennium, the bill passed the State Senate unanimously. Late in this year’s session, the House unanimously passed a revised version of the bill with mainly technical corrections requested by the NC Medical Board. The Senate failed to act further on the bill prior to adjourning, so the bill has not become law. However, there still is an outside chance it could be considered when the legislature comes back for one of their mini sessions throughout 2022.

The NCAFP leadership believes this is a notable example of how scope of practice changes and discussions should take place: in a collaborative manner, with incremental change, where experience and practice setting still matters, and where team-based care is valued.

APRN Scope – Once again this year, the nursing community pushed for legislation that would completely eliminate physician involvement with Advanced Practice Registered Nurses (H277/ S249). The bill would have allowed a newly minted APRN to practice independently with no scope restrictions from their first day out of school. NCAFP and the entire House of Medicine strongly opposed the bill. Unlike the bill aimed at Physician Assistants, the legislation had no safeguards in terms of

experience or type of practice setting. In addition, the proposed legislation went much further than legislation passed in any other state in the last several years. Legislation passed recently in other states (Virginia and Florida, for example) had experience requirements for APRNs.

As stated above, the Senate made this issue much more complicated when that Chamber tacked this bill, along with several other significant regulatory reforms on to their proposal to expand Medicaid. While the NCAFP has always supported Medicaid expansion, our leadership found many of the other provisions (particularly the provisions around APRNs) untenable at best. The Senate ultimately passed this bill, but it stalled in the House, with the House passing a different version of Medicaid expansion without all the other reforms included. This represented the first time that a bill addressing APRN independent practice had ever passed out of a committee, much less a complete chamber of the General Assembly.

Late in the session, one of the bill’s key sponsors tried a parliamentary move to force the House Speaker to bring the stand-alone APRN bill to the floor, which was at least temporarily thwarted. The NCAFP continues to remain heavily engaged in this important issue.

Primary Care Pipeline

The NCAFP has been working on several initiatives to increase the primary care pipeline in recent years. This year, we focused on efforts to increase incentives for choosing family medicine, particularly in rural areas.

House Bill 1090 would have funded 12 annual $25,000 scholarships to medical students who would commit to go into family medicine in rural areas. It is patterned after a program that was available in the 70s and 80s in our state, but at some point was defunded. The scholarships would revert to loans if the medical student did not enter family medicine or did not practice in a rural area. But for those who did end up practicing rural family medicine, the students would avoid paying significant interest by receiving up-front scholarships versus loan repayment after the fact. All four House Health Chairs served as primary sponsors of the bill, which would have initiated a four-year pilot. A group of 11 other bipartisan House members also served as sponsors.

The NCAFP and Community Care of North Carolina worked closely together on the legislation. While we were not surprised that the bill did not move as a standalone piece of legislation, it came remarkably close to being included as part of the budget. At one point, the funding had increased from $1.5 million to $7 million for the pilot. However, given that the budget is a second-year adjustment of the biennium, some legislative leaders did not want to fund any “new” programs. On the positive side, both House and Senate Health Chairs believe we have a great chance of funding this effort during the 2023 legislative session because of the strong support it received this year.

The NCAFP also continues to work with others to try to find ways to incentivize precepting, particularly in rural and underserved areas. We know that early and frequent exposure to rural Family Medicine is positively correlated with medical students ultimately practicing in those areas.

Administrative Burden Reduction

Due to the speed and intensity of the legislative session, we were unable to move forward legislation aimed at reducing administrative burdens. However, we continue to talk to legislative leaders about the need for reforms. We have had particularly positive conversations around reducing Prior Authorizations and expect legislation could be filed to address this topic in 2023. We also continue to work with payers to address administrative burden in primary care, including sharing the results of a survey the NCAFP completed on the topic in 2021.

In conclusion, we believe we are on the precipice of passing several pieces of legislation that would have a positive impact on family physicians and your patients, either later this year or next year. We will keep you updated in our e-newsletter and this magazine as our efforts continue.