Moore doctor turned state official pitches Medicaid reform proposal

Apr. 03, 2014 @ 12:20 PM

This article has been corrected to replace all references to Medicare. Cummings' proposal only addresses Medicaid.

Dr. Robin Gary Cummings, a former Pinehurst surgeon, is now leading the state’s efforts to reform Medicaid. On Wednesday, he was in Sanford as part of a statewide tour to promote the plan.

The crux of the reform is to create groups of medical providers — primary care doctors, surgeons, specialists and others — called accountable care organizations (ACOs). Those organizations would have incentives to reign in Medicaid overspending: They would have a spending target, and if they save the state money, group members would get a share of those savings. Yet if there were overruns, they also would have to share the costs.

“The goal is to deliver quality care but also control costs,” Cummings said of the reform plan, which he developed in his role as deputy secretary of the state Department of Health and Human Services. The plan won’t just be enacted right away, however. It must first be approved by the General Assembly. Cummings said the goal is to have the ACOs up and running by July of 2015.

He acknowledged concerns that doctors who are personally invested in the cost of patient care might skip some tests or procedures in order to preserve their own bottom line. So there would be safeguards in place, Cummings said, to counter that possibility. Each ACO would be graded on a set of metrics such as patient feedback, length of stay, repeat hospitalizations and a variety of other categories that the state would enforce via financial penalties.

“Let’s say you saved $10 million at the end of the year, but you didn’t meet your care metrics.” Cummings said. “You don’t get any of those savings. That’s how strong it is.”

He said the medical industry supports the plan despite such safeguards, which are based on the policies of other states with similar setups. He added that he hopes the creation of ACOs would lead to doctors spending more time considering individual cases rather than just ordering a battery of tests and scans and “churning through” their patients.

He said that if all goes according to plan, at least 90 percent of North Carolina’s 1.8 million residents on Medicaid should be covered by an ACO by the end of the decade. In large counties, there might be four or five such groups, he said, whereas areas like his old practice area of Moore County would likely have one or two.

He also said his plan would increase the focus on behavioral and mental health, while also streamlining mental health services.

“We want to focus on coordinated care,” Cummings said. “You can’t separate the head from the body.”

Cummings’s boss, DHHS Secretary Dr. Aldona Wos, said she expects his plan would cut Medicaid costs by 2 or 3 percent, saving the state hundreds of millions of dollars.

“We have an obligation — an obligation we have willingly accepted as a state — to help those in need,” Wos said in a press release. “And we must, at the same time, be good stewards of taxpayer resources. We believe this Medicaid reform plan is responsive to both those obligations.”

Not all legislators are on board, however.

Sen. Louis Pate (R-Lenoir), one of five people on the state’s Medicaid reform committee, told the Triangle Business Journal last week that he doesn’t think Cummings’s plan necessarily guarantees fiscal stability. The federal government pays the vast majority of the state’s $13.5 billion annual Medicaid expenditures, but slight fluctuations can still change the state’s budget by millions of dollars.

“Medicaid should provide predictability, and I don’t believe that the plan as it’s currently written provides the predictability that we need,” the TBJ reports Pate as saying, also adding that he wants to put it off another year at least.

Cummings, however, said Wednesday he believes he has a solid plan that would be good for patients and for the medical community, as well as state coffers, and that reform shouldn’t be delayed any longer.