Meeting date: January 16, 2018 at 9:00am
Presiding, Representative Lambeth (Co-Chair)
Tuesday, January 16, the Joint Legislative Oversight Committee on Health and Human Services met to discuss various topics on the agenda. To see the full agenda, click here.
(Note that the final item was pushed to the next meeting on February 13th due to time running out). My notes below consist of the discussion portions of the meeting following each respective presentation. To see the full presentations/slideshows, click the links in each section, or here for the entire list of presentations.
Regarding the format of these notes, the question/comment by a committee member was recorded (unless otherwise specified), followed by the arrow –> and then the respective answer by the presenter.
Presentation: Comments from Secretary – Secretary Mandy Cohen
Update on Cardinal Innovations
Discussion:
In response to Rep. Dollars request to clarify CFAC –> (Cohen) Consumer and Family Advocate Committee; 20 voting members, 3 of which are consumer family advocates from constituted CFAC committee.
Cohen: Confidence of Board going forward – larger board; going through significant amount of training and orientation. Some of the same people on previous board.
Sen. Krawiec: Do we know what the chances are that taxpayers will be able to recover funds that were in violation of statute? –> (Cohen) Legal question, and lawyers are looking at it now and at what the legal options are.
Rep. Earle – Term limits? –> There are currently term limits as set forth in statute.
Rep. Earle – Would think there are enough people in the state to fill positions without having to reselect same people from board to serve again.
Rep. Cunningham – When will corrective action plan be ready for us to view? –> Hope in the next several weeks
Update on Influenza Data in NC
The worst is yet to come – there’s still time for folks to get flu shot before we see most of the cases (typically in February, but may be a little earlier this year).
Discussion:
Rep. Fisher – NC seemed to be one of last states to reach threshold of being noticed for having the flu. Thoughts? –> Can conjecture about difference of temperature, etc. Can have epidemiologist follow up on it.
Rep. Murphy – Is 10% efficacy rate accurate? –> Yes, we are seeing a good match this year with types of flu. We are seeing a virulent strain, so while it may be covered by vaccine, it’s really intense. So, we are seeing people who get sick get much sicker. It’s never perfect, which is why you want to make sure you’re getting the flu shot so that if you do get it, it isn’t as severe.
Rep. Lambeth – Any areas with shortage of vaccine? –> No, but some shortages in items like IV bags. Nothing in shortage related to vaccine though.
Sen. Tarte – Physicians are asking when they’ll get paid for vaccines –> Did make a change, so Dave will go through specifics; Will ensure payments are made before end of fiscal year. Making changes in NC Tracks to address payments.
Rep. Lambeth – When will reports start coming through? –> A few are left outstanding, and you should have them soon. If anything is urgent and will require more action, let us know.
Presentation: Office of Program Evaluation Reporting and Accountability (OPERA) Report – Denise Thomas & Rod Davis
OPERA Background (Denise)
- Address shortage of data that of effectiveness on DHHS programs
- Evaluating DHHS programs using evidence based methodologies
- As of 2017 session, DHHS hadn’t established office or hired director; 2017 appropriations bill reserved funds for OPERA
- Report was submitted before Dec. 1st, which is in front of committee members.
(Rod Davis – CFO, DHHS) – Summary of actions, recommendation
Discussion:
Sen. Hise – Do you understand how frustrating this is for members of NCGA? Three years ago, NCGA thought it was important enough to create an office dedicated to this. We feel that programs are not evaluated based on their outcomes…Yet, another report that department hasn’t done anything yet. Perhaps department doesn’t want anything done or to create it. Do you know how frustrating it is to have this happen for a third year? –> Yes, and we want to do better. Initially thought we should find a director and then he/she can find staff. We haven’t found the right candidate(s) yet.
Sec. Cohen – While we have waited on hiring a director, we haven’t waited on doing the work. Want to think about how to use funding appropriated for this to beef up systems we currently have as opposed to building something new. Want to continue to build data system structure. Asked department to do the function and work in order to make the position better work.
Sen. Hise – Should we assume that additional funding isn’t needed? –> (Cohen) Additional funding in this area always allows us to do more than we are now. Funds have been tied up.
Rep. Dobson – Usually try to give people benefit of the doubt, but agree with Sen. Hise completely on this one. Has position been posted in past three years? –> Yes, director’s position has been posted and some candidates have been interviewed.
Rep. Dobson – Statute is not a suggestion. You are required to follow statues in place. I don’t know that OPERA is best way to get to where we want to be, but it’s in statute. If you can’t find good candidates, I would like to help with that.
Senator Krawiec – Salary for this position? –> Not sure.
Sen. Tucker – We have seen numerous times where DHHS has ignored statues and had no response. Info staff is getting over the years is better than it has been. But, this is here for a reason. If it isn’t the best way, we need to do something different. Accountability is difficult in our society today, and numbers and data holds people accountable. Where are we with date on a fraud program with Medicaid payments? –> (Richard) We previously reported that we have begun process. We have engaged vendor to ensure NC Tracks system will be in place by the Spring. Making sure it’s funded.
Sen. Tucker – Can we say it will be April 1? –> Would prefer later in April, but will be done during the Spring.
Sen. Tucker – So April 30? –> Will let you know if it won’t be by April 30
Rep. Dollar – You said work was ongoing even though office hasn’t been set up. So, is there a particular work product that can be shared with this committee that’s directly in line with what’s been requested during budget over the years? –>Yes. Would be happy to follow up on this and explain platform used to aggregate data.
Rep. Dollar – Would like to see list or summary of activities for committee to evaluate.
Sen. Barringer – Rylan’s Law depends on data and accountability in order to move forward with transparency. Regarding pilot program in New Hanover with Child Protective Care Services. Hear that it’s helping. Feedback? –> Clarification that reference is to program that’s making sure worker has adequate data to ensure best decisions are being made.
Sen. Barringer- Specific timeline to evaluate this program? Strategy? Surrounding areas are also interested. –> Timeline over this year for rollout, and may even come in during another session to give update. There are changes we need to make in policy because of Federal Regulations, and we need to make sure these are addressed.
Sen. Barringer – To clarify, what is specific plan to implement New Hanover pilot program around state? Is there one? If not, what’s the plan to make a plan? (The program that allows social workers to have the info they need before stepping into a situation that typically involves families – Duke Endowment) –> Rollout of technology is critical. Not just change in tech, but also change in workflow. Training on tech and integration in necessary. Goal is to have this across the state by the end of this calendar year. Want to do more homework and then will get back to you.
Rep. Lambeth – Please share director job description and salary with us. We may know someone suitable.
Related article from Carolina Journal Frustration crosses party lines over DHHS failure to create watchdog
Presentation: Update on Cherry and Broughton Hospitals – Mark Benton, Deputy Secretary for Health Services, DHHS
Discussion:
Rep. Dobson – Took tour of Broughton a couple weeks ago. Regarding the addition of 85 beds at Broughton and 97 at Cherry, how far has this taken us from where we need to go? –> It helps, but it’s not just about number of beds we have. It’s also about the ability to move patients through hospital and out of the hospital (discharge back to community). Problem is that there’s often nowhere for us to discharge them. Complicated, so never a ‘this will fix everything’ scenario. I am thinking about how we prevent people from getting so sick that they need to go to the hospital in the first place, and how do we properly get them discharged and back into the community? Full circle mindset.
Rep. Lambeth – (Re: slide 3) Reworking and extending contract, who paid for that? –> (Benton) Some fixes were reworked by contractor that was corrected as part of initial contract value/cost.
Sen. Tucker – Cost per bed at Cherry and Broughton? –> Don’t have exact numbers, but each has total budget/year around $1M-$1.5M. Think it’s around $1000/bed. Will check.
Sen. Tucker – Clarification, cost of construction per bed. Number given seemed excessive. –> Can follow back up. Different than general construction because entire hospital needed to be built according to certain hospital standards (security, fire walls, protection, etc.)
Sen. Tucker – What about old Cherry hospital? Certain parts were very sufficient to being utilized. Did we just moth ball all of that? –> Don’t have current update on that, but will give you that and link back to comment (Secretary made) on utilizing vacant buildings
Presentation: Health Information Exchange Update – Christie Burris, Director, NC HIEA
Presentation: DHHS Collaboration and Partnership Efforts – Sam Gibbs, Deputy Secretary for Health Services, DHHS
Discussion:
Sen. Hise – First deadline coming up with electronic health records. Anything we can do to make sure it goes smoothly? –>In first year of operation, we focused on certain health centers for which we had concrete numbers (focused on hospitals, health systems, community health centers), we know who exactly they are, over 90% of hospitals and health systems signed to participate with NC Health Connex; 87% of health departments; signing last FQHC. June 2020 – includes docs, PAs, specialists, wider range…don’t have the exact denominator there to give an exact number. We are doing a provider entity resolution project with SAS which providers are Medicaid only, health plan only, both. Denominator can be reported on this in less than six weeks.
Sen. Hise – Do you see current deadlines as they exist as realistic goal? Or will NCGA need to take more action? –> Deadlines are quite aggressive. Can’t speak with confidence that every provider impacted by deadline will be in compliance by deadline. Extension process is a great effort; nobody wants to see a provider drop out of a program because they are not in compliance with the law. The study – gives legislature good feedback and data on recommendations to get everyone on board.
Sen. Hise – Last iterations that want to come on… hold out to only offer data on Medicaid patients. Is there any way where NC Connex can get all the information possible on patients (not just those on Medicaid)? –> Advisory Board decided approximately one year ago to have providers elect to give information. Commitment from healthcare systems to be full participants in future HIE. Working with systems to come to full participation agreement with which they are comfortable.
Rep. Murphy – Trying to wrap head around concept and how it logistically works (he uses different medical record than the hospital does.) I can understand the information from the State Health Plan and Medicaid being involved, but do patients have to sign a release of information who are with BCBS, Aetna, etcetera, that allows the HIE to have their information? I say this in the dawn of cyber security etc., that people’s health records are out there. Now, we are asking them to put them in an entirely different place where their access can be obtained. –> NC is opt-out state, so all patients are automatically opted in to system until they opt out. Education to patients are required, so when provider signs document, HIEA provides provider with educational info and encourages them to add that to patient disclosure.
Rep. Murphy – Will patients be able to access their own records through HIE? –> Not at this time, and asked NCGA if it’s something they’d like to offer in the future. Having a patient access the system and be able to see who is looking at their stuff is good. There are two types of connections. For larger systems and larger more sophisticated type of technology practices, that electronic health record (EHR) system has a real-time connection to the HIE. At the time the event occurs, it will be sent to the HIE, which really helps with actual data in the hands of people who are using the data.
Another type of connection for older systems and smaller physician practices; batch file transfer to HIE. That is required by law to submit information twice daily, currently, more often than not, happening once daily.
Rep. Murphy – For small, rural health care providers and needing to use EHR…are they being charged to do this? –> We are providing funds back to provider to help them; Study looking at cost; Quite costly (not just the purchase), but time and resources to train their docs and to really learn how to use it; We don’t charge a fee, there are no participation fees; We do not have control over what fees are by EHR vendors for their customers, we are trying to be transparent with our provider communities, which is in part why we held EHR vendor day – to talk about requirements, etc. help EHR community know that this is part of the vision for state to drive managed care, holistic care
Rep. Dollar – If someone is not a Medicaid patient but a private-pay person, concern about state agency having medical records. Comments on that concern? –> We have to think about the data that is coming into the HIE in two ways; At the Micro level – de-identify data from all payers is really going to help NC move to managed care; It’s going to help look at whole patient care; truly know where that patient touches the system, whether he or she rolls on and off a certain health insurance plan, to really have a full visibility into that patient’s health record, will you truly be able to help improve the health outcomes of that patient? So, that’s the micro level.
Rep. Dollar – cost to providers? –> Can vary from $5k to $millions, depending on technology and patients. Keeping in mind concern for smaller physician practices.
Rep. Dollar – Millions of dollars isn’t practical for smaller providers, which include smaller specialty doctor offices, smaller pharmacies, small dentist practices, etc. –> Acknowledge that behavioral health is a different animal, and hope to get LMC/MCO hooked into system soon. (Burris – hope to have this by 2020)
Sen. Tarte – Concerned. Don’t think North Carolinians understand the clinical info is now owned by state of NC. They have option to opt out, but never had option of opting in. Troublesome.
Rep. Lambeth – Anything next session to keep it on track? –> May bring back some recommendations on things that can be done to help
Read related blog from JLF’s Katherine Restrepo (January 2018) Big Data Has Big Goals for NC Medicaid Program
Presentation: LME/MCO Performance Standards and Accomplishments – Steve Owen, Mark Benton, Dave Richard
Sec. Cohen – Keep question in mind: When is variance needed?
Mark Benton – Talk about various data points being monitored. Want to kick off conversation with financial investments provided to LME/MCOs and size of population they have wo serve.
Discussion:
Sen. Tarte – Emergency care. Why not have urgent care on site of hospital/ER and then they can direct? –> (Cohen) Some ERs have triage to determine where patient should go. How do we do things in community to make sure folks know ER isn’t only open door to them. Hope to talk about this in larger plan.
Sen. Tarte – Statutorily restricted from having urgent care on site? –> Not prohibited, but would want attorneys to walk through how it can be done properly.
Sen. Hise – Holes in evaluations from budget side is, “are those funds going back into community and being used as they’re meant?” Within first 6 months, fund balance (money they’re holding) has grown despite the cuts. We feel money we are investing is going into reserve fund. We are all hearing from constituents on how more money needs to be going to services to build capacity in community. Frustrated. How do we make that part of evaluation of system? –> (Richard) Want to determine right number (investment). Tolerance level of cash on hand, and then use that to determine reinvestments. Sec. Cohen has been clear on reinvestment expectations. Want to see community investments that off-set higher-cost services. Welcome the conversation and recognize the system was designed for reinvestment purposes.
Discussion b/w Sen. Tucker and Secretary Cohen: (Tucker referenced big new buildings, Wilkes County, questioned accountability) –> (Cohen) Need to be wary of proper time spent in order for funds to be spent wisely. Don’t want to have unintended consequences where funds are quickly spent to, say, build another building in order to rid of reserve funds quickly.
Rep. Dollar – Can you provide additional comments regarding fund balance and issue of making sure we are reinvesting? –> Complicated issue. Begin at looking at drivers and seeing which LME/MCOs are making money. Look at medical loss ratio (money spent on services vs. not). Start off at unequal points, and then it’s a matter of looking at available cash. Seems like it would be simple to do, but it’s not. Money gets tied up in many different ways.
Rep. Lambeth – Have to cut off discussion for time, but haven’t heard anything new today. It’s all the same that I’ve been hearing since I’ve been here. Let’s resolve some issues so we can move forward.
Presentation: LME/MCO Approaches to Addressing the Opioid Crisis – Brian Ingraham, CEO, Vaya Health
Western North Carolina
Discussion:
Are you documenting when a single patient uses Narcan? –> We don’t, but state officials know. We aren’t involved with counting or decision making, but it is being done.
Sen. Davis – Important to have actionable data to know how many doses people are needing to get properly treated.
Sen. Krawiec – You said most people have gone to nasal sprays because it’s easier to administer. Heard it’s a huge price difference/cost savings. –> Can’t speak specifically to cost, but nasal spray is more expensive. Harder for people to learn how to do other injections, so it was worth extra costs for us. With our high-volume buys, it does drive cost down some.
Rep. Cunningham – Option for people to revive themselves if repeat patients, rather than having cost of them in hospitals? Trends in other drugs? –> Number of prescriptions and pills are being reduced, but replaced by other drugs. NC is a state that allows for open prescription of naloxone.
*Next presentation (Status of Strategic Plan for the Improvement of Behavioral Health Services) will carry over to the next meeting on February 13.*
