32

Appendlx 1: WrlLLen CommenLs from Medlcald 8eform Advlsory Croup

!"##$% '( )*++,

1o: Aldona Wos, Mu. , SecreLary, uPPS
lrom: uennls 8. 8arry, Chalr, Medlcald 8eform Advlsory Croup
Sub[ecL: CommenLs 8egardlng urafL roposed Medlcald 8eform lan, 2014
-./'0!12/-0.
ln Lhe maln, Lhe drafL of Lhe roposed lan Lo 8eform Medlcald ln norLh Carollna ls a good and
LhoughLful plan. lL clearly makes Lhe case and need for Medlcald 8eform wlLh whlch l concur.
lurLher Lhe proposed plan has been developed ln order Lo bulld on Lhe exlsLlng sLrengLhs of Lhe
currenL care sysLems operaLlng ln nC. Clven some more mlnor commenLs below, l fully
endorse Lhe proposed Medlcald 8eform lan.
lL ls lmporLanL Lo recognlze LhaL Lhe LranslLlon from a largely fee-for-servlce sysLem Lo a more
value based sysLem ls noL an easy LranslLlon and Lherefore lL wlll Lake Llme, especlally as lL
relates to creating the needed Medicaid Accountable Care Organizations (ACOs). It will take a
number of years Lo develop new organlzaLlons LhaL dellver care, allgn lncenLlves, monlLor
quallLy and Lake rlsks ln order Lo more effecLlvely serve Lhe Medlcald beneflclarles of norLh
Carollna.
The Advisory Groups role in development of this plan has been an interesting journey and I
would be remlss lf l dld noL Lhank Lhe members of Lhe group (SenaLor Louls aLe,
8epresenLaLlve nelson uollar, ur. eggy 1erhune, and ur. 8lchard CllberL, Mu) for Lhelr many
conLrlbuLlons and devoLed servlce Lo Lhls efforL. Also, havlng wlLnessed Lhe Lremendous efforL
LhaL has been puL forLh by uPPS sLaff and Mr. 8ob ALlas, consulLanL, ln creaLlng Lhls proposed
plan, l would llke Lo Lhank Lhem for Lhelr efforL and leadershlp as well.
llnally, as parL of Lhese lnLroducLory commenLs, please be advlsed LhaL Lhe Advlsory Croup dld
noL have Lhe opporLunlLy Lo revlew Lhe pro[ecLed esLlmaLed cosL savlngs of Lhls 8eform lan.
1herefore, l wlll noL have any commenLs regardlng Lhls secLlon of Lhe reporL.
Accountable Care for Physical Health Services (ACOs)
1he followlng are commenLs regardlng Lhls flrsL secLlon of Lhe proposed plan:
1. The definition and/or description of organized groups of healthcare providers must
clearly lndlcaLe LhaL such groups lnclude a broad array of prlmary and speclalLy care
MDs, hospital care, and many other related groups and services who are willing to

33
come LogeLher Lo share rlsk, allgn lncenLlves, measure and lmprove quallLy and manage
Lhe care of Medlcald beneflclarles.

2. Clven Lhe lnlLlal organlzaLlonal cosLs and sLaLed admlnlsLraLlve funcLlons of an ACC, lL ls
clear LhaL lnlLlal sLarL-up caplLal wlll be requlred. ?eL Lhere ls no provlslon for fundlng
sLarL-up caplLal ln Lhls plan. Some conslderaLlon should be glven for sLarL-up
caplLallzaLlon ln Lhe form of a loan, under cerLaln slLuaLlons ln whlch prlvaLe flnanclng ls
unavallable.

3. Although Im impressed wlLh Lhe sLaLed ACC coverage goal for year 3 aL 90 of Lhe
appllcable Medlcald populaLlon, l do belleve LhaL Lhe goal should be, vlrLually, 100. All
beneflclarles should have Lhe opporLunlLy Lo access Lhe avallable ACC sysLem(s) ln all
geographlc area of Lhe sLaLe by Lhe end of Lhe flfLh year.

4. 1he mlnlmum number of Medlcald beneflclarles ls sLaLed aL 3,000. AlLhough Lhls
mlnlmum goal ls okay for Lhe lnlLlal lmplemenLaLlon phase, l cerLalnly hope and suggesL
LhaL Lhe mlnlmum slze needs Lo be lncreased over Llme, reachlng aL leasL 23,000 by Lhe
end of Lhe flfLh year.

3. Primary Care provider exclusivity: The report states that primary care MDs can only be
part of one ACO, although specialty MDs are allowed to belong to more than one ACO.
1he excluslvlLy provlslon may be approprlaLe for Lhe lnlLlal years of developmenL,
however, a more flexlble pollcy regardlng C excluslvlLy should be consldered for ouL
years(beyond year 2) in order to provide PCPs the ability to belong to more than one
ACC. 1hls ls especially needed when you have potentially competing ACOs, or PCP
organlzaLlons LhaL cover a slzable amounL of geography.

6. lrequenL changes of prlmary care physlclans (every 30 days) are hlghly problemaLlc as
currenLly requlred by CMS. Pavlng a prlmary care home ls vlLally lmporLanL, especlally
over Llme. 1herefore, Lhe frequency of Lhe ablllLy Lo change a medlcal home should be
every 6 monLhs or once a year versus every 30 days, as ls now Lhe case. Such a change
would be beneflclal Lo Lhe care of Lhe paLlenL.

7. uual Lllglble: lL ls very lmporLanL Lo allgn Lhe flnanclng and care managemenL programs
beLween Medlcald and Medlcare. uual Lllglble beneflclarles are some of Lhe mosL lll
and cosLly of all Medlcald paLlenLs. 1he dlfferlng parameLers of Lhe 2 programs have
frusLraLed Lhe creaLlon of a more efflclenL dellvery and care managemenL sLrucLure for
these patients. Given the development of ACOs, it will more possible to work with LTSS

34
and MP, SA and l/uu sysLems ln creaLlng beLLer soluLlons for Lhls speclal populaLlon of
paLlenLs. ConslderaLlon for lncludlng such poLenLlal soluLlons and relaLed flnanclng ln
future required waivers, is important.

8. Savlngs and Losses: 1here should be some ablllLy Loward acceleraLlng Lhe mlx of
savlngs and losses over Llme, lf an ACC deslres and ls quallfled Lo assume more rlsk wlLh
uPPS approval.

!"#$%& ("%&$)* +,-.$%#/" 0-,." %#1 2344 +5.$"6
1he followlng are commenLs regardlng Lhe MenLal PealLh secLlon of Lhe reporL:
1. Although consolidation of 10 LME/MCOs into 4 is hlghly deslrable, l cannoL sLress Loo
much Lhe need for sLandardlzaLlon across many admlnlsLraLlve areas. Cne of Lhe key
crlLlclsms LhaL l heard LhroughouL Lhe SLaLe ls Lhe varlablllLy of deallng wlLh dlfferlng
LML/MCC sysLems, lncludlng bllllng, credenLlallng, quallLy reporLlng, eLc. 1herefore l
sLrongly encourage all efforLs Lo sLandardlze slmllar process across LML/MCC
organlzaLlons.

2. 1he MenLal PealLh, SubsLance Abuse, l/uu SysLem ln nC. PlsLorlcally has been
consldered an lnsLlLuLlonal cenLrlc sysLem. Tomorrows system must be more
communlLy based ln boLh Lhe array and capaclLy of needed servlces. 1oward LhaL
goal, we should mlnlmlze or ellmlnaLe Lhe 1913(c) walver program walLlng llsL by
creaLlng a slgnlflcanL number of addlLlonal walver sloLs, Lhereby reduclng Lhe overall
cosL of carlng for Lhe speclal needs and l/uu populaLlon ln nC.

78#9 :";6 <%;" %#1 +,==8;$. +5.$"6
1he followlng are commenLs regardlng Lhe L1SS sysLem secLlon of Lhe reporL:
1. Cne of Lhe mosL perslsLenL problems ln long Lerm care ls Lhe conLlnuaLlon of Lhe
relaLlonshlp beLween Lhe beneflclary and Lhelr C lf Lhey move Lo a long Lerm care
faclllLy. SomeLlme Lhe faclllLy ls some dlsLance away from Lhe C and aL oLher Llmes lL
slmply ls noL an efflclenL use of Lhe C Lo see Lhe paLlenL ouLslde Lhelr offlce. LxacLly
whaL Lhe soluLlon(s) ls for Lhls problem ls, aL besL, eluslve. Powever, Lhls ls one of Lhose
problems LhaL musL be consldered as parL of Lhe sLraLeglc plannlng efforL. WheLher
conLlnuaLlon of Lhls hlsLorlc relaLlonshlp is feasible or not and to what extent ACOs
lnvolvemenL wlll be deslrable, are key quesLlons LhaL need Lo be explored.


33
2. ln Lhe L1SS arena, Lhere are a varleLy of new programs LhaL have a more flexlble fundlng
base Lhan LradlLlonal servlces and are communlLy based. rograms such as ACL and
AdulL uay Care Lo name several. Llke MenLal PealLh, we should move our LradlLlonal
array of L1SS servlces Loward a more communlLy based model of needed servlces. Such
a Lrend would be hlghly deslrable.

!"#$%#&'(# *+',-+&$#&.(,
1he proposed plan of 8eform proposes Lo make Lhe cosL of ouLpaLlenL prescrlpLlons more
accountable to both ACOs and LME/MCOs, which I support. However, to the extent that the
currenL sysLem of accounLlng for rebaLes does noL reflecL Lhe acLual neL cosL of Lhe prescrlpLlon
drug wlLhln Lhe Medlcald sysLem, Lhen Lhls needs Lo be changed. 1hls ls especlally Lhe case lf
rebates differ amongst drugs and brands. We must use net cost when holding both ACOs and
LME/MCOs accountable.

/'((&, 01 2%++34 56%&+
7'8&-%&8 0'9.+: ;8<&,.+3 =+."$

Cc:
SenaLor Louls aLe
8epresenLaLlve nelson uollar
ur. eggy 1erhune
ur. 8lchard CllberL, Mu


36
!"#$"%"&'(')*" ,"-%.& /.--($
,0 1.2%" /)%'$)3' 45
Servlng: Cary, Apex, SwlfL Creek, Polly Sprlngs, Carner and luquay-varlna
C 8ox 1369, Cary, nC 27312 (919) 649-7690

March 17, 2014


TO: Aldona Wos, M.D.
Secretary, N.C. Department of Health and Human Services

Dennis Barry
Chair, Medicaid Reform Advisory Group

RE: Comments on the Departments Proposal to Reform North Carolinas
Medicaid Program
________________________________


I want to thank my fellow members of the Advisory Group and the staff and consultants at
DHHS for their important and insightful contributions toward reforming our Medicaid program.

North Carolinas Primary Care Medical Home (PCMH) model was first developed under
Governor Jim Martin and since has become a nationally recognized model of reform that other
states have sought to emulate. The PCMH model has contributed significantly to controlling the
growth of Medicaid claims spending while improving our States healthcare outcomes. As
echoed in this proposal, it is vitally important to build on the strengths of our system.

True Medicaid reform must be transformative and incremental in order to ensure
success. Provider upside and downside risk is an essential component of the next stage of any
reform effort. However, the transition to risk must be in such a way that current levels of patient
access and quality of care in North Carolina are improved, not interrupted. I support this
Medicaid reform plans use of Accountable Care Organizations (ACO) if we build upon the
current foundation of the primary care medical home model that exists in all 100 counties. Other
states developing Medicaid ACOs are looking to our PCMH model as the foundation of their
medical neighborhoods.

The proposal endorses and recommends refining the Behavioral Health Reforms initiated by the
General Assembly in 2011. I believe the ongoing consolidation of LME/MCOs operating the
1915(b) and (c) waivers is in the best interest of the state, consumers and their families. Once
consolidation is achieved these systems, with governance boards appointed from and
answerable to their communities, will be in a position to significantly improve the quality of care
and close the gaps in our Mental Health System. Working with the LME/MCOs we will be able
to achieve coordination of care between a persons behavioral health home and their medical
home.


"#
The majority of direct long-term care services funded by Medicaid fall under two major
categories; Skilled Nursing Facilities and Medicaids optional Personal Care Services (PCS).
Skilled nursing in North Carolina has been a stable and reliable part of our healthcare
continuum for many years. However, the PCS program (provided in adult-care homes and in-
home) has undergone extensive reworking by the General Assembly and the Department in
recent years to address a range of difficult issues. These and pressures from the USDOJ and
others have led to instability and uncertainty in the long-term care industry. The proposals
recommendation to take more time for additional study of long-term care services and supports
is prudent and appropriate.

The Department should consider submission of the pending federal grant proposal for dually
eligible individuals (those qualifying for both Medicaid and Medicare services). This proposal,
developed by the full range of stakeholders, could provide immediate improvements to the
coordination and integration of care, as well as, save state and federal resources.

Information and data are the keys to significant improvements in our Medicaid system. As
discussed in the proposal, the Department also needs to successfully institute reforms in the
leadership, management, and operations of the Division of Medical Assistance, while providing
staff with the best available tools and support to achieve the programs goals and objectives.

North Carolina is blessed to have world-class medical centers and research institutions with a
wealth of knowledge across the full range of medical and behavioral health. As the Medicaid
Reform process moves forward, we must marshal the considerable talent, knowledge and
resources available in our State. Healthcare is a complex endeavor which requires the
sustained engagement of all stakeholders. The best solutions will be found by fully engaging our
States extensive resources. By doing so we can create a system that will serve our citizens
well into the future.

These comments and recommendations are not intended to be an exhaustive response to the
Departments Medicaid Reform Proposal. Additionally, the Medicaid Reform Advisory Group did
not convene to discuss and make recommendations as a group. The Proposal itself is a broad
outline which envisions and will require considerable additional engagement and work once the
General Assembly has completed its review and determined the most appropriate course.

This proposal does represent an important and historic reform as we move away from paying
only for quantity of services provided and move toward value-based purchasing that rewards
health care providers for delivering high quality care in a cost-effective manner.


cc: Richard Gilbert, M.D.
Peggy Terhune, PhD
Senator Louis Pate


38
!"#$%&' )* +",-.&/0 1*2*

1o: Aldona Wos, M.u., SecreLary, and uPPS
lrom: 8lchard L. CllberL, M.u., M8A, Member, Medlcald 8eform Advlsory Croup
8L: Draft Proposal to Reform North Carolinas Medicaid Program (Proposal)
uaLe: March 14, 2014
l applaud Lhe goal of Covernor McCrory, 1he Ceneral Assembly, SecreLary Wos, and uPPS Lo make
meanlngful reform Lo Lhe norLh Carollna Medlcald rogram. 1hls reform wlll Lransform Medlcald Lo
enhance quallLy of care, assure paLlenL access, aLLaln cosL effecLlveness, and achleve flscal predlcLablllLy.
lL has been a prlvllege Lo serve wlLh my colleagues on Lhe Medlcald 8eform Advlsory Croup, Chalrman
uennls 8arry, SenaLor Louls aLe, ur. eggy 1erhune, and 8epresenLaLlve nelson uollar. Chalrman
uennls 8arry has done a mosL admlrable [ob provldlng leadershlp and guldance LhroughouL Lhls process.
Many Lhanks Lo 8ob ALlas, Mardy eal, MaLL Mckllllp, and Lhe uPPS sLaff for Lhelr dedlcaLlon,
commitment and outstanding work in developing this Proposal. Importantly, this process has
poslLlvely engaged and exLenslvely soughL lnpuL from paLlenLs, provlders, Lhe communlLy and oLher
sLakeholders. noLwlLhsLandlng Lhe commenLs and recommendaLlons whlch follow, l endorse Lhls
Proposal to Reform North Carolinas Medicaid Program.
age 12- b Processes Pertaining to Beneficiary Health Care Management SuggesL 3) develop a
sLaLlsLlcally valld audlL process Lo valldaLe quallLy ouLcomes reporLs, 6) develop a conLlnuous quallLy
lmprovemenL process whlch measures, reporLs and lmproves lndlvldual pracLlLloner performance, buL
prlmarlly focuses on ldenLlfylng and lmprovlng sysLems lssues.
age 13- Speclflc expecLaLlons of ACCs - SuggesL - Speclflc educaLlon and Lralnlng of rovlders and SLaff
Lo enhance Lhe aLlenL Lxperlence.
age 13- rlmary Care rovlder LxcluslvlLy SuggesL Addlng - C asslgnmenL Lo an ACC should be based
upon Lhe C nl number raLher Lhan Lhe pracLlce 1ln number.
8eneflclary AsslgnmenL Lo ACCs - SuggesL Addlng - ln order Lo promoLe proacLlve populaLlon healLh
managemenL lncludlng buL noL llmlLed Lo chronlc dlsease managemenL and prevenLlve care measures,
Lhe ACC and C musL know beneflclary asslgnmenLs aL Lhe beglnnlng of Lhe enrollmenL year,
asslgnmenL should noL be made reLroacLlvely. lrom an acLuarlal rlsk Laklng perspecLlve, ls a mlnlmum of
3,000 beneflclarles for an ACC adequaLe?
age 16 b. Changes of prlmary care provlders - Agree LhaL effecLlvely managlng beneflclarles ln an
accounLable care envlronmenL wlll be dlfflculL lf beneflclarles can frequenLly change ACCs. SuggesL -
beneflclarles may be able Lo change Cs every 30 days buL only Lo Cs wlLhln Lhe same ACC for a
glven year.
age 20 Catastrophic costs - AppreclaLe Lhe lnLenL Lo mlLlgaLe lmpacL of caLasLrophlc cosLs by
excluding from calculation 90% of claims costs above $50,000 in a twelve month period. Expect thaL
ulLlmaLe pollcy deLermlnaLlon wlll be made based upon acLuarlal daLa and analysls.

39
age 21 - SuggesL addlng Lo Lhe llsL of meLrlcs whlch should recelve flnanclal lncenLlves: paLlenL
saLlsfacLlon scores (paLlenL experlence), paLlenL safeLy lnlLlaLlves, lower cosLly medlcal compllcaLlons,
ACC lmplemenLaLlon of daLa drlven quallLy lmprovemenL programs, cosL effecLlve use of
pharmaceuLlcals lncludlng buL llmlLed Lo maxlmlzlng use of generlc drugs, lmplemenLaLlon of evldence-
based medlclne.
Ceneral - If you cant measure it, you cant manage it has been attributed to the legendary
managemenL consulLanL, eLer urucker. 1he degree Lo whlch Medlcald 8eform ls deemed successful wlll
ln parL be based upon achlevlng boLh flnanclal and quallLy performance benchmarks. 1o LhaL end, lL ls
lmporLanL LhaL Lhe veraclLy of Lhe daLa ls assured so LhaL all parLles share a slmllar veLLed daLa seL. 1hls
wlll enable all sLakeholders Lhe lnpuLs Lo evaluaLe as Lo wheLher performance LargeLs have been
achleved.
The following is suggested to be incorporated into this Proposal - llnanclal AudlL - An annual
lndependenL flnanclal audlL/revlew wlll be conducLed Lo provlde sLrucLured and LransparenL flnanclal
performance outcomes, assumptions and comparatives to the ACOs, DHHS, the Governors Budget
offlce and Lhe llscal 8esearch ulvlslon.
CuallLy AudlL - An annual independent audit of designated Quality Measures (Quality Performance
Balanced Scorecard) will be conducted to provide structured and transparent quality performance
outcomes, assumptions and comparatives to the ACOs, DHHS, the Governors office and LeglslaLure.
8especLfully SubmlLLed,
!"#$%&' )* +",-.&/0 120 134
8lchard L. CllberL, Mu, M8A
Chlef Medlcal Cfflcer
Amerlcan AnesLheslology












"#


"#


62
!"##$ & '"()*+", !)-.-, /01, 234 /5+6(7)

1o: Aldona Wos, Mu. , SecreLary, uPPS
lrom: eggy S. 1erhune, member, Medlcald 8eform Advlsory Croup
Sub[ecL: CommenLs 8egardlng urafL roposed Medlcald 8eform lan, 2014

89':4.;2'849
As an experL ln MP/uu/SA servlces ln nC, l have found Lhe process of developmenL of Lhls plan Lo be an
exclLlng opporLunlLy Lo asslsL ln creaLlng a plan for Medlcald 8eform ln norLh Carollna LhaL ls based on
research and sLakeholder lnpuL whlle belng lnnovaLlve and creaLlve. 1hls plan bullds on naLlonal exlsLlng
and emerglng besL pracLlces Lo creaLe a darlng and vlable plan LhaL wlll allow nC Lo once agaln lead Lhe
naLlon. As our Ceneral Assembly seeks Lo be flscally prudenL wlLh Lax payer dollars, l applaud Lhls efforL
Lo ensure LhaL sLakeholder lnpuL has been sollclLed and llsLened Lo, and sLrongly urge Lhe sLaLe Lo
conLlnue Lhese efforLs golng forward.
My commenLs are prlmarlly relaLed Lo my experlence as a provlder of MP/uu/SA servlces ln nC as well
as my background ln pollcy developmenL. 1hey are commenLs based on my knowledge of Lhe currenL
sysLem and Lhe Lremendous amounL of lnformaLlon LhaL l was prlvlleged Lo revlew from sLakeholders
who wanLed Lo ensure LhaL Lhey could flnd Lhelr volce ln Lhls reporL. Llke you, l belleve LhaL everyone
wlll flnd someLhlng Lo llke ln Lhls reporL, and someLhlng Lhey dlsagree wlLh. Powever, l feel LhaL for Lhe
mosL parL, lL seLs a dlrecLlon for norLh Carollna LhaL can be flscally prudenL whlle meeLlng healLh care
needs for our clLlzens.
l appreclaLe and respecL Lhe vlews and dedlcaLed hard work from Lhe resL of our commlLLee (uennls
8erry, Chalr, SenaLor Louls aLe, 8epresenLaLlve nelson uollar, and ur. 8lchard CllberL, Mu.) as well as
LhaL of Lhe sLaff and consulLanLs. lL has been an honor Lo serve wlLh Lhese knowledgeable and
esLeemed colleagues.
llnally, as parL of Lhese lnLroducLory commenLs, please be advlsed LhaL Lhe Advlsory Croup dld noL have
Lhe opporLunlLy Lo revlew Lhe pro[ecLed esLlmaLed cosL savlngs of Lhls 8eform lan. AlLhough l wlll noL
have any speclflc commenLs regardlng Lhls secLlon of Lhe reporL, l wlsh Lo hlghllghL some LhoughLs.
1he lasL of Lhe LMLs became managed care enLlLles only a year ago. 1he experlence of Lhe lnlLlal MCC,
Cardlnal lnnovaLlons, demonsLraLed LhaL savlngs ln MM occurred !"#$ &'(#. Learnlng how Lo
maxlmlze savlngs whlle lmprovlng quallLy ls noL easy there is no recipe or one right way to do this. It
ls based on declslons made one by one, worklng wlLh lndlvlduals before any sorL of aggregaLe savlngs
can occur. Cnly wlLh experlence and hlsLory wlll we galn savlngs. 8ased on Lhe sLellar performance of
MCCs ln reduclng cosL and lncreaslng quallLy, even ln Lhelr flrsL full year of operaLlon, l belleve LhaL Lhe
ACC model wlll evenLually creaLe huge savlngs. Powever, a very large shlp Lakes Llme Lo Lurn, and our
leglslaLors and admlnlsLraLors wlll have Lo be paLlenL as Lhe learnlng curve develops.
l also cauLlon Lhe deparLmenL agalnsL movlng Loo qulckly Lo reduce MMs for MCCs and expecLed
savlngs from ACCs. l would encourage Lhe deparLmenL (and Lhe leglslaLure, Lhrough lLs budgeL) Lo allow

"#
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64
!""#$%&'()* ,'-* .#- /0123"') 4*')&0 5*-63"*2 (ACOs)
1he followlng are commenLs regardlng Lhls flrsL secLlon of Lhe proposed plan:
1. l compleLely supporL Lhe concepL of ACCs. 1here are several ln norLh Carollna LhaL are worklng
wlLh Medlcare and have demonsLraLed LhaL Lhe model ls cosL effecLlve and quallLy drlven. l
would cauLlon, however, LhaL ln every sysLem, Lhere ls never one model LhaL accuraLely flLs all
people. My concern ls for people who have severe and perslsLenL menLal lllness (SMl).
8esearch has demonsLraLed LhaL Lhese lndlvlduals dle on average 23 years sooner Lhan Lhelr
average llfe expecLancy ls due Lo lack of medlcal care. Clven Lhe naLure of Lhe menLal lllness and
aL Llmes homeless sLaLus, Lhese lndlvlduals slmply do noL geL medlcal or prevenLaLlve care or
LreaLmenL. 8lood pressure or ulabeLes LhaL goes unchecked resulLs ln hlgh expense Lo Lhe
sysLem and poor quallLy of llfe for Lhe lndlvldual.

2. I applaud the departments suggestions for potential co-locaLlon seLLlngs and recommend LhaL
ACCs plloL programs wlLh varlous models LhaL could enhance Lhe sysLem wlLhouL Laklng away
from Lhe ACC concepL. SMl and l/uu healLh homes are belng plloLed naLlonwlde wlLh
excellenL resulLs.

3. l sLrongly suggesL LhaL Lhe deparLmenL look aL lessons learned from MCCs. opulaLlon
expecLaLlons for 3000 parLlclpanLs may be flne for Lhe flrsL year or Lwo, buL wlll noL be large
enough Lo susLaln Lhe Lypes of savlngs needed ln Lhese organlzaLlons. SLarL-up fundlng wlll be
essenLlal, as a revlew of MCC sLarL-up expenses can agaln predlcL some of Lhe lnvesLmenL cosLs
needed.

7*%&') 4*')&08 5$(2&'%"* !($2* '%9 :;<< 512&*=
1he followlng are commenLs regardlng Lhe MenLal PealLh secLlon of Lhe reporL:
1. My flrsL commenL perLalns Lo a slgnlflcanL expense ln Lhe plan. Whlle Lhe ACCs are Lo be
monlLored on access, cosL, and quallLy, Lhe MCC secLlon deLalls much more overslghL, reporLlng,
and monitoring. I have noted that in the past this burden is at times not value added. It is
compounded by Lhe facL LhaL Lhese burdens are passed Lo provlders who agaln dupllcaLe cosL
for non-value added acLlvlLles. 1he sLaLe has a cholce. Pold MCCs accounLable for access, cosL,
and quallLy such as ACCs, or conLlnue Lo dlcLaLe many addlLlonal daLa and reporLs LhaL can be
revlewed and dlscussed. Whlle such hand holdlng ls admlrable aL besL and lnLruslve aL worsL, lL
ls noL cosL effecLlve. CreaLe sLandards on access, cosL, and quallLy and ellmlnaLe anyLhlng else
LhaL ls sLaLe drlven and noL needed for federal reporLlng. 8ulld accounLablllLy lnLo Lhe sLandards
and !"#$ &'() *+$ ,'() *--".+/*0#12 uo noL creaLe a sysLem where Lhere ls noL a way Lo
ellmlnaLe a poor performlng group. 1hls ls unfalr Lo Lhe oLhers of LhaL group, and ulLlmaLely
unfalr Lo boLh consumers and Lhe Laxpayers who supporL Lhe sysLem.

2. l am encouraged LhaL nC ls wllllng Lo look aL Lhe llsL of people walLlng for servlces ln MP and uu,
currenLly abouL 9,300 lndlvlduals. 1hese numbers wlll only lncrease as elderly parenL careglvers
dle and baby boomers age. 1here have been many dlscusslons durlng Lhe developmenL phase
of Lhls reporL abouL whaL oLher sLaLes are dolng and have done Lo ellmlnaLe Lhelr walLlng llsLs. l
would encourage Lhe deparLmenL Lo revlew CMS prlorlLles for communlLy llvlng and move Lhose
legacy models of servlce lnLo new evldence based supporLs LhaL have been demonsLraLed Lo
dellver lower cosL and lmproved quallLy. 1hls can provlde Lhe cosL savlngs Lo serve many more
nC clLlzens.

63

3. One of the frequent comments I have heard is, The devil is in the details. The overarching and
phllosophlcal LeneLs ln Lhls plan are excellenL, buL Lhe plan wlll succeed or fall based on Lhe
deLalls. 1he norLh Carollna Councll on uevelopmenLal ulsablllLles worked wlLh a group of
sLakeholders from all Lypes of dlsablllLles and all parLs of Lhe sLaLe Lo ldenLlfy Lhe values LhaL wlll
gulde Lhe underplnnlngs of reform. l recommend LhaL as deLalls are developed, Lhe sLaLe follow
the adage Nothing about me, without me for consumers, providers (BH and primary health
care), hosplLals, and oLhers. l also suggesL LhaL Lhe value sLaLemenLs developed by Lhe nCCuu
workgroup be conLlnually referred Lo as declslons are made, wheLher declslons are Lo be made
abouL flscal maLLers such as MMs, quallLy measures, or access lnLo Lhe sysLem. ln Lhls way, all
sLakeholders can be parL of Lhe soluLlon. ln addlLlon, we have brllllanL and person focused
unlverslLy researchers and pollcy developers ln nC who can help Lhe deparLmenL crafL Lhese
deLalls.

"#$% &'() *+(' +$, -.//#(01 -210')
1he followlng are commenLs regardlng Lhe L1SS sysLem secLlon of Lhe reporL:
1. l agree wlLh Lhe lnLenLlons Lo sLudy Lhe long Lerm care sysLem vla a group of lnvolved
sLakeholders. l encourage Lhe deparLmenL Lo conslder new and communlLy based opLlons over
legacy Lype servlces. eople should be allowed to age in place and retain the dignity they
have en[oyed ln Lhelr llfeLlmes even as dlsease and consequences of age advance. 8esearch Lells
us LhaL Lhe baby boomers wlll requlre and demand communlLy servlces and supporLs far greaLer
Lhan brlcks and morLar healLh care opLlons can provlde. We musL look Lo new communlLy based
models lf we are Lo avold collapse of Lhe sysLem as baby boomers age.

2. AlLhough noL descrlbed speclflcally ln Lhls reporL, lndlvlduals who age are also members of Lhe
flrsL Lwo populaLlon groups dlscussed. As we Lry Lo break down sllos Lo galn economles of scale
for flscal and quallLy lmprovemenLs, we musL noL forgeL LhaL Lhe l/uu sysLem also provldes
lnLermedlaLe care faclllLles (lCl) of a sllghLly dlfferenL naLure. 1here are many areas where Lhe
aglng sysLem could work wlLh Lhe l/uu sysLem Lo save cosL and lmprove quallLy. Whlle Lhls ls
someLhlng LhaL many people ln boLh flelds Lalk abouL, l am noL aware of any vlslble plloL
lnlLlaLlve Lo enhance coordlnaLlon and collaboraLlon beLween Lhese sysLems. 8oLh groups wanL
Lhe same values ln sysLems LhaL are dellneaLed ln Lhls secLlon of Lhe Medlcald 8eform 8eporL.

3.0/+04'$0 5('16(4/04#$1
1he followlng are commenLs regardlng Lhe rescrlpLlon secLlon of Lhe reporL:
1he proposed plan of 8eform proposes Lo make Lhe cosL of ouLpaLlenL prescrlpLlons more accounLable
to both ACOs and LME/MCOs. MCOs actually already review this data, and provider physicians have
access Lo excellenL daLabases Lo glve lnformaLlon LhaL can resulL ln more approprlaLe prescrlblng. 1hls
has made a dlfference ln behavloral healLh prescrlpLlon cosLs. 1haL ls noL Lo say LhaL Lhls can be
lmproved, alLhough lL should be noLed LhaL Lhls already occurs on some level.

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