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Another last-minute blitz at the General Assembly?

If there’s been one area in which the current leadership of the General Assembly has been at its most cynical when it comes to directly contradicting past promises and rhetoric, it’s almost certainly in the area of legislative process. It’s gotten to the point at which it seems that scarcely an important piece of legislation advances on Jones Street without some kind of abuse of legislative rules (or, at least, the spirit thereof). Whether they’re crafting budgets in secret,  holding unannounced, middle-of-the-night sessions, providing lack of time and opportunity for public comment or just springing entirely new legislation out of thin air as last-minute  amendments, both the House and the Senate have frequently seemed intent of bending every guideline of fair play and open government.

And, of course, the amazing thing about all of this is that it’s not even necessary even from a crass, down-to-brass-tacks political perspective. The leaders in both Houses have huge, rubber-stamp majorities that make such shenanigans utterly unnecessary.  Sometimes it feels as if leaders are engaging in such exercises just because they can.  See for example, last week’s decision by House leaders to spring a last-minute, out-of-nowhere amendment on Senate Education Committee chairman Jerry Tillman on Common Core legislation.

So, with the final days of the 2014 session apparently upon us, observers of the General Assembly will do well to pay very close attention over the next week or two. Indeed, the House Finance Committee meets at 5:00 pm today to take up a bill that’s been sitting on its calendar since last summer and that will almost certainly be gutted and entirely rewritten with a “committee substitute.”

The bottom line: Notwithstanding the Senate’s just-for-show talk of making budget negotiations open, it’s almost a certainty that the upcoming days will  feature loads of secrecy and bad, behind-closed-doors lawmaking. Stay tuned and watch closely if your stomach can take it.

One Comment

  1. Jeffrey Harris

    June 24, 2014 at 4:32 am

    It is so unfortunate that the Senate has demonstrated such ignorance of the systems in NC that have provided frequently cited information on the cost benefit associated with Medical Homes.
    I came here in 2001 to work with Community Care of NC following the sale of my company to Aetna Health. The technology we sold allowed Medicare Advantage Programs to identify, target and engage at-risk seniors through referral to primary care case management. It was clear at that time that the lessons learned from the world of HMO managed care had reached the end of their useful life as physicians had learned about the concepts of cost control through limiting redundant procedures and using evidence based guidelines in the 1980’s. The 1990’s brought us minimal returns in Disease Management which was the initial model deployed by Carolina Access’s efforts in Asthma and Diabetes population management activities. Those in the US that were on the cusp of ‘the next big thing’ were organizing for Primary Care Case Management through regional networks. I had spent 1999-2001 making presentations to the likes of Aetna, United Health Care, PACE and Empire Blue Cross to sell our intellectual property. If the commercial insurance industry understood the value of the marriage of technology with Medical Homes in 2001 it was a sure bet that our entire delivery system was on the verge of major payment reform.
    Having had these successes in the private sector, my wife and I moved to NC after learning about the evolving Medicaid program which ultimately was titled Community Care of NC. We had a sincere desire to see a replication of a successful private industry venture through the public systems of care.
    Since I was from the ‘evil private sector ‘I often heard ridicule from folks working in public programs here in NC. However; the willingness of these people to adopt information technologies that would increase their understanding of the Medicaid population and facilitate the design of delivery systems to tackle specific risks for the State of NC and separate regionally-managed community centered action plans for twelve regional networks was undoubtedly supported by the experts and General Assembly alike. Since that time it has become clear to all who work in the field of population health and disease management that the involvement of local providers, patients, payers and institutions in the creation of these programs is critical to the success in terms of both return on investment and quality of care.
    So here we are: Those of us fortunate enough to work with these teams learned many lessons. When I left CCNC in 2006 I worked nationally, implementing similar programs across multiple states. I frequently heard how impressed various leaders in healthcare were with North Carolina’s success at improving the health of persons with diabetes and asthma as well as making a significant dent in the inflation rate in NC Medicaid when compared with other States.
    So why would the Senate disband a working solution. I witnessed the reports from various budget experts at the public forums held last spring and noted a general lack of proper methodology when reporting cost data. For example: There was no evidence of proper control group selection and illness burden adjustment. When I stated to a former Senate member who happened to be a surgeon the errors in the reports used by the committee to compare cost benefit he agreed with me and stated “We really are not sure what questions to ask”: Yet the citizens of NC place their trust in this group to reform Medicaid.
    Of course, when the public was asked for input, the decision was made to keep the existing program. Obviously many became clearer on the benefits. Then, out of left field comes enough controversy and distrust to once again, throw out the baby with the bath water.
    Now that I am retired the muzzle of political correctness is no longer relevant. So here is some more feedback that is based on actual happenings in my life since working in NC.
    I returned two weeks ago from the Patient Centered Primary Care Collaborative, a 10 year old group spawned from the private sector in response to the escalating costs of care in this country along with the fact that we are rated far down the line in healthcare outcomes when compared with at least seven other industrialized nations; few of whom conform to what we like to think of as traditional socialist thinking. I hold a co-chair position with this group and have gratitude for hearing the current thinking of the ‘best and brightest’ a club of economists and CEOs which I certainly do not qualify for membership.
    During the conference a lead executive in a fortune 100 company along with several others from other organizations respected by all who read the Wall Street Journal told me that he had been asked to consult with the Governor’s office after the GA changed its mind about Medicaid outsourcing. He asked me what I thought and I gave him feedback on my personal observations of the successes achieved by Community Care of NC and told him a story about a similar plan assembled in Chicago in 2007 where I had a consulting contract. The Chicago plan failed since the commercial HMO and technology vendor had not developed succinct written requirements. I recall the meetings as if they were yesterday: Especially the frustration I exhibited in public when I found out that the HMO had not connected with the Medicaid primary care providers in Chicago prior to submitting their proposal. So here I had evidence of a public –private partnership success story in NC and private failure in Chicago.
    My business friends that had reviewed the politics and business cases in NC for our Governor had all recommended that the State keep CCNC and the Accountable Care Organization models that had been promised only two months ago. Unfortunately their actual comment to me was: “Sorry Jeff, we do not understand the logic, the drivers appear to be something other than cost and quality. Perhaps it is time for you to leave.
    What more can I say. The Senate’s budget is counter-intuitive yet those who are emotionally trapped by their opinions concerning the ACA seem unwilling to discuss the details as to why it makes no sense.
    Does the GA realize that the Triad had a huge problem with mothers using the emergency room when their children became dehydrated from GI influenza and that the local CCNC network assembled a clinic to educate mothers to master the task of orally rehydrating their kids when they were sick which brought down the ER visit rate to almost nil? How do they think an HMO will be able to address local needs with such specific detail and provide educational resources?
    I have had diabetes for 48 years. I remember when Blue Cross sent my refrigerator magnets to remind me to have tests performed and monitor my blood-sugar. I have no idea how much my employer paid for that Disease Management Service but I do know that I had to argue for my insulin pump in 1984: The one tool that I attribute my lifespan to today.
    I will close with this:
    For the last six months I have been working with some private practice ophthalmologists who are willing to treat Medicaid diabetics. Many specialists will not treat Medicaid patients due to the lower reimbursement but these folks are a dream team. I assembled a program description and took it to the NC Medicaid Medical Home leadership to get their feedback. They were very pleased to see local people getting involved with creating specialty networks that would treat their patients. Why? Well we have a problem with diabetics becoming blind if they are on Medicaid due to inadequate access to specialty care. So here I was offering a bundled service at ½ the commercial rate charged by the hospital next door.
    Unfortunately, I have had to place the project on hold. One of our major criteria for inclusion in the retina service for diabetics is that they are tethered to a Medical Home. As of a few weeks ago I can no longer assume we will have a relationship with a Medical Home enterprise.