The Joint Legislative Oversight Committee on Health and Human Services met on November 14, 2017. The notes below highlight some of the meeting’s most important developments:

Committee Members: Click Here

Committee Meeting Documents: Click Here

Senator Pate, Presiding Co-chair

 

Comments from Mandy Cohen, MD, Secretary Department of Health and Human Services:

NC Tracks Enhancements to Prevent and Detect Fraud, Waste, and Abuse (S.L. 2017-57, Sec. 11H.15)

• There is no electronic means of keeping track of who is deceased to avoid fraud/abuse

 

Telemedicine Study and Recommendations

Maggie Sauer, Director, Office of Rural Health Department of Health and Human Services

Timely study with access to care for citizens and folks with special needs across state

Report: 35-page doc (particularly pages 6-9)

• Broadband coverage would serve us well as we look at this
• Not a separate service, but a mode of delivering care
• *Talking about providing quality access to care for folks who normally might not be able to access it another way –> creating strategies and policies to give this access to quality care
• Adopt the Health Resources & Services Administration (HRSA)’s definition of telehealth and telemedicine.
• Want to ensure standard of care though telemedicine is consistent with other care settings
• Engaging practitioners to provide care at the top of their licenses.

Acceptable communication and data transfer speeds necessary

• North Carolina Office of Broadband Infrastructure 2017 Broadband Report recommendations should be enacted quickly –>Development of communities à need to establish good transfer speeds for telehealth services (for increased access to care in rural communities)
• Eligible providers and institutions should participate in NC HealthConnex
• Covered entities and business associates must follow all federal and state regulations to secure protected health information
• Adopt the American Telemedicine Association’s standards for informed consent –> Make sure people understand what services they’re receiving and how they receive it –> make sure patients understand their rights, responsibilities, etc. just as they would in an office-setting visit
• Online prescribing standards –> Recommends following all federal regulations for E-Prescribing
  • Ryan Haight Online Pharmacy Consumer Protection Act
  • Controlled Substances Act

• Want to make sure people are following licensing standards in NC, but also have other opportunities for these licensed people to practice across state lines –> Interstate Medical Licensure Compact (NC has not yet adopted), which is overseen by Federation of State Medical Boards (FSMB)
• Medicaid payment for telemedicine services, but not a standardized payment system among insurance providers –> opportunities for DHHS and NCGA to figure out what that looks like
• NC Psychological Association –> believes NC should create legislation to participate in Psychology Interjurisdictional Compact (PSYPACT)

Comments/Questions 

Rep. Adcock – ‘Telemedicine’ vs. ‘Telehealth’ –> Believes we should be using term ‘Telehealth,’ because Telemedicine falls into that term.

Rep. Dobson – On private payer reimbursement standards, that seems to be one of most challenging obstacles. Does Department have recommendations on this and how the state moves forward?

Sauer – We do have some reimbursement policies around telemedicine around Medicaid and CMS. We really are trying to look at additional opportunities to measure science around telemedicine. We don’t have a lot of info around efficacy around this. We want to better understand how that looks in terms of being better or the same, and we have opportunity to define what this looks like.

Secretary Cohen – Don’t view this as paying piece by piece like in other health settings, but telemedicine can fit into overall health of someone (as part of larger payment model, capitated). Two tracks we need to follow:

• 1 Track: Infrastructure and regulations
• 2 Track: Evidence based data

Rep. Lambeth – Do you have inventory of what is happening now across NC with telehealth?

Secretary Cohen – We have some of that, and some surveying, though not comprehensive. This is how we found out there are gaps in evidence-based data. Opportunity to partner with insurance providers, like BCBS.

Rep. Murphy (MD) – Limitations to this, but hands down there are things that can be handled through telemedicine. Agrees that difficulty is going to be private payers. Most challenging population is going to be Medicaid population, as many of them use Emergency Departments for primary care. Those are populations that also don’t typically have access to devices used in Telemedicine. Will be a requirement for some people on Medicaid to use this rather than going to ER as primary care. However, some of them simply won’t do it. We need to be pragmatic. Moving forward, there will need to be some requirements that they use this service.

Secretary Cohen – We aren’t saying someone should use this instead of face-to-face encounter, but as a complement to it. To your point, one state that we have spoken with is Tennessee. Group that works with Community Health Center to provide telemedicine.

Senator Hise – Committee directs staff to draft legislation based on these recommendations – submit to ITO oversight for broadband issues. Asks Department to submit language for incorporating telemedicine into waiver/legislation.

Secretary Cohen – We are already thinking about how to incorporate telemedicine into waiver. Asking CMS if we can use this.

Senator Krawiec – Are you aware of grant programs/funding programs through USDA grant program in rural areas? Can we take advantage of this?

Sauer – Absolutely. USDA, Commerce, many departments are looking at this, and Duke Endowment, has put money into this. Number of grant programs that are trying to sponsor this and create pilots so that they do have the data moving forward.

Rep. White – In review of other state programs, any collaboration with homecare and public health (especially because sometimes, there does need to be that hands-on care).

Sauer – Yes, and in NC. Roanoke, Chowan –> telemonitoring program that has been very successful. Difficulty is that this isn’t necessarily paid for…but does lead to better overall care and prevents them from having to go to ER.

Rep. Cunningham – Preventative means should also be covered

Senator Davis – Regarding controlled substances and opioids, are there unique challenges with telemedicine that will make it challenging for us to know who is prescribing what to whom? Especially across state lines…

Secretary Cohen – Related to reporting systems, need to make sure we have that access across state lines. Standard we want to adopt is e-prescribing practice, having access to that information across state lines.

Related articles by JLF’s Katherine Restrepo:

Don’t Force Insurance Companies to Pay for Telemedicine Services

Telemedicine Working Faster Than The Government To Improve Health Care Access

Update: January 2018 – Full Report on Telemedicine

 

DHHS Strategic Plan to Address the North Carolina Opioid Crisis

Mandy Cohen, MD, Secretary, Department of Health and Human Services

&

Susan Kansagra, Section Chief, Chronic Disease and Injury Section

DHHS Division of Public Health

Secretary Cohen – Dr. Susan Kansagra is at forefront of addressing opioid epidemic within Department.

Dr. Kansagra – 3 people die each day from opioid overdose in NC (will soon be 4 people)

• Death rate is directly correlated to areas of high dispense rate
• Shift to elicit/synthetic drugs over the years
• 50% of opioid overdose Emergency Department visitsà uninsured/self-pay
• Need access to long-term treatment and recovery (Medicaid)
• Key initiatives among involved stakeholders

Action Plan Strategies:

• Reduce oversupply of prescription opioids
• Reduce diversion of prescription drugs and flow of illicit drugs
• Increase community awareness/prevention
• Make naloxone available
• Expand access to treatment and recovery-oriented systems of care
• Measure impact and revise strategies based on these results

Coalition for Model Opioid Practices:

• Hospitals & Health Systems
• DHHS
• NCGA

STOP Act – Prescriber Provisions (Effective January 1, 2018)

• Limits first-time prescriptions of targeted controlled substances for acute pain to ?5 days
• Prescriptions following a surgical procedure limited to ?7 days
• Allows follow-up prescriptions as needed for pain
• Limit does not apply to controlled substances to be wholly administered in a hospital, nursing home, hospice facility, or residential care facility
• Dispensers not liable for dispensing a prescription that violates this limit

Payers Council (first meeting in December) –> public + private payers to identify, align, implement policies that:

• Support providers in judicious prescribing of opioids
• Promote safer and more comprehensive alternatives to pain management
• Improve access to naloxone, substance use disorder treatment and recovery supports
• Engage and empower patients in the management of their health.

Synthetic Opioid Control Act (SB 347/HB 464) –> will close loopholes in controlled substances act to capture substances like fentanyl

Naloxone Distribution –> DHHS purchased and distributed nearly 40,000 units of naloxone in October.

• Distribution via opioid treatment programs, NC Harm Reduction Coalition, EMS agencies/first responders, and other community partners

ECHO Project Pilot –> DHHS funding UNC to offer for providers:

• Free DATA – 2000 training
• Weekly case-based learning ECHO clinic
• In office support for providers interested in training and strategy support for medical assistants, nurses, and office staff in their practices.
• One to one provider case consultation
• Working on an expansion of access to the ECHO clinic, DATA-2000 training, and CME credits to providers in all 100 counties

Medicaid pharmacy benefit changes –> in August, implemented prior approval for opioid analgesic doses that:

• Exceed 120 mg of morphine equivalents per day
• Are greater than a 14-day supply of any opioid
• Are non-preferred opioids on the NC Medicaid Preferred Drug List (PDL)

Medicaid pharmacy benefit changes –> In November, prior authorization removed for suboxone film.

• Suboxone –> prescription drug used for Medication- Assisted Treatment (MAT) –> Allows quicker access for patients who are ready to commit to treatment

New Partnership–>HIDTA (High Intensity Drug Traffic Area)

• Coalitions funded by White House Drug Coordinating Office and CDC/DEA
• In NC, has created public safety/public health collaboration
• Providing new reports using ED data to move from passive to active outbreak surveillance
• Provides real time data for law enforcement to use

Synthetic Opioid Control Act (SB-347 / HB 464) –> lists all known fentanyl derivatives as controlled substances –> creates new “catch-all” provision describing the chemical backbone structure of the fentanyl molecule in order to capture any future fentanyl derivative that may be encountered here.

• Various other changes to update and modernize controlled substance act, at request of law enforcement.

Questions/Comments

Chairman Dobson – (Referring to slide 3) Seems to be over-prescription and death in rural areas. Is there over-prescription in rural areas? If so, why?

Cohen – Yes, there is a link between overprescribing and then subsequent overdose deaths. Multifactorial reasons –> in some areas, there is more chronic pain. Overall, access to providers and knowledgeable providers could be a factor.

Rep. Dobson – What all does helping people through long-term treatment programs entail?

Secretary Cohen – Need to make sure they have insurance options to utilize treatment programs.

Rep. Murphy (MD) – NC as a whole has decreased by about 15% opioid prescriptions. Finding that people are going directly to heroin. Recommend that while doing telemedicine, opioids not be available to prescribe. Also, opioid users can refuse to be taken to hospital, thus refusing that care and treatment. Greatest challenge is getting these people into treatment programs.

Rep. Murphy – Any update on prescription drug disposal?

Secretary Cohen – Looking at that issue now, and have had great partnerships in doing so (especially through pharmacies). Working to further partnerships.

Rep. Dollar – What are we doing to address synthetic rise?

Dr. Kansagra – Have seen exponential increase in this, and from multiple sources. Traffickers are creating increasingly novel fentanyl compounds. This is where law enforcement colleagues are crucial –> to identify source of trafficking into our state.

Rep. Dollar – Good deal of substance abuse work is operated through LME/MCO grants. One thing to consider is bringing some of those reps to speak with us and discuss it from their prescriptive. Have you tracked what kinds of diagnosis you see most often involved in over prescribing? Any info on that (i.e. knee pain, back pain, etc.)?

Dr. Kansagra – Varies based on physician, but NCHA is working to identify guidelines based on procedure/surgery types.

Rep. Dollar – Will they actually have the data to be able to identify procedures where this is prevalent, or not prevalent?

Dr. Kansagra – That’s one of the things we are looking at now. The data sources do provide some of this information to us, so we are looking to get a better sense of it.

Rep. Dollar – Internal assessment?

Dr. Kansagra – Data collected from wide variety of stakeholders. Measure e-visits in addition to other stakeholder metrics, such as naloxone distribution.

Rep. Dollar – In opioid action plan, care is being management now to LMC/MCOs, and they are a key element moving forward. Should ask to hear from them.

Senator Hise – We expected to see death rate fall following naloxone distribution/access. It is actually increasing though. How do you change prescribing mechanisms during opioid treatment program?

Dr. Kansagra – Neuroscience is different, and therefore treatment is different. Will be working on figuring out best way our state programs/centers can fit into larger effort.

Rep. White – Number one complaint from constituents is that there is no easily accessible/relatively close treatment center

Rep. Cunningham – Cost estimate to state for overdoses? Have demographics changed since interception of crisis?

Dr. Kansagra – We know the cost to society isn’t only on healthcare, but also loss of productivity, to law enforcement, etc. Cost across country is more than $75B when taking all of those factors into consideration. Would we rather pay now or pay later? If we put more up front, we can save it later down the road.

Secretary Cohen – Should also focus on prevention (such as if you are prone to depression à treatment; or have back pain –> physical therapy)

Senator Foushee – What else can NCGA do to fight opioid epidemic?

Cohen – Increase capacity of state to treat people –> increase access to insurance for recovery and support (long-term support and care)

Rep. Adcock – Great to invite LME/MCOs to talk about treatment options for Medicaid options. But no one should think this is only poor population’s problem; they aren’t carrying burden alone. Even people who have insurance have access issues to residential treatment –> sending people to Florida and other states that have residential treatment centers.

Controlled Substances Reporting System (CSRS) Update

Charles Carter, Chief Operating Officer for Technology and Operations

DHHS Information Technology Division

• Currently in process to procure new vendor for CSRS, so will need to be careful on how to discuss it right now. Looking at goals on how to proceed with CSRS platform, and what next steps will be.
• Interstate connectivity is crucial, especially to take control on epidemic. Vendor must be able to do this.
• Wants vendor that can integrate within Electronic Health Record (EHR)
• Will be able to look at new technological standards available to see if there are any that can be brought into NC

To achieve future state:

• CSRS vendor contract extension for next calendar year (current one ends December. 31, 2017)
• Execute MOU with National Assoc. of Boards of Pharmacy for interstate connectivity
• Procure vendor that fully meets CSRS goals given by NCGA
• Develop process to integrate all provider’s EHR to new platform (no cost to providers) (should be able to provide real time data in today’s technological world)
• Train dispensers and providers on new platform

Questions/Comments

Senator Pate – Any certain vendor in mind? Do we have to find a new one, or just think we should?

Carter – Not in negotiations with any specific vendor, but looking at options right now in marketplace. Contract ending in December is with an older platform. Gives us a healthy opportunity to look at what else is available in marketplace.

Rep. Murphy – What has been Epic’s record of success to provide more user-friendly platform?

Carter – One standard for new vendor is to have an easy connection of EHR and to Epic.

Rep. Murphy – Why can we not do this in-house, with the new HIE on board?

Carter – Our goal is to come in under cost. Have had multiple conversations with vendors, and shouldn’t have a problem coming in under cost NCGA allocated.

Rep. Murphy – Concerned about cost to providers. Please don’t let big companies bully you around just to put one more cost on providers.

Senator Jim Davis – Understanding you are within budget, and maybe under budget. How close are we to having nationally recognized platform?

Response – There’s a lot of work going on at federal level to share information, develop standard, etc. Challenging because no one wants to give up their current system. Doesn’t mean everyone has to have same vendor, but just the same standard. Currently a work in progress.

Report on Use of the Dorothea Dix Hospital Property Fund to Increase Licensed Inpatient Behavioral Health Beds

Steve Owen, Committee Staff

&

Mark Benton, Deputy Secretary for Health Services, DHHS

 

Benton – $2M allocated from Dorothea Dix Hospital Property Fund for construction of Facility Based Crisis Beds for Children/Adolescents

• $18M allocated from Dorothea Dix Hospital Property Fund for conversion/construction of licensed short-term, impatient Behavioral Health Beds

Questions/Comments

Cohen: In response to Senator Pate’s comment about it – Cherry Hospital opened Sept. 2016 à push to hire more staff and to bring more beds.

Related article by JLF’s Becki Gray: CON waiver to allow for rural hospitals acquire or convert inpatient mental health hospital beds  

 

Traumatic Brain Injury

Mark Benton, Deputy Secretary for Health Services, DHHS

&

Dave Richard, Deputy Secretary for Medical Assistance, DHHS Division of Medical Assistance

Adult and Pediatric TBI Pilot Program –> Program’s Purpose: To increase compliance with internationally approved evidence-based treatment guidelines

• Will focus on adult and pediatric populations with severe classification of TBI. (Individuals with Glasgow Coma Scales of 3 to 8)
• Will occur at 3 to 5 trauma hospitals licensed by the state.

Goals:

• Reduce patient mortality
• Improve patient recovery level
• Reduce long-term care costs

TBI Overview & Stats

• Centers for Disease Control and Prevention (CDC) estimates prevalence rate of TBI to be 2% of population –> 200,000 North Carolinians
• 113,852 consumers who had TBI diagnosis in at least one of seven diagnosis code positions using applicable ICD-9 codes

Questions/Comments

Rep. Dollar – Frustration with waiver. Doesn’t seem like it has been a priority. Have been trying to get it done for a long time, and NCGA has provided money over a couple different sessions. Legislature established brain injury advisory council. What has been Dept.’s interaction with this council? Any comprehensive reports?

Response –Shared frustration on waiver; everyone on team shares it. State had requirement to create injury-based services to CMS. Waiver had to meet all compliance rules. For new waiver, had to meet new requirements. Should get waiver done rapidly, and we are looking forward to getting this done quickly and have expressed so to CMS. Have had great interaction with advisory committee. Have assigned staff to attend meetings and work directly with them. We have comprehensive view on what is needed, which is why waiver was developed in the first place.

Rep. Cunningham – Why is acquired brain injury not included?

Response: From beginning, has been traumatic brain injury. Looking at options on this moving forward.