Letter from WCMS Member Dr. Harald Kowa to NCGA Senators & Representatives

September 14, 2015

Dear Senator/Representative,

As I have explained in a previous email, competition between PLEs (Physician Led Entities) and MCOs (Managed Care/Cash Organizations) is not possible.  PLEs provide medical and mental health services to individuals, and MCOs take money from individuals and set up administrative filters to prevent money from flowing back out to patient care. There is no competition at a meaningful level.  And there are guaranteed administrative burdens that take money from patient care in the MCO model.


WE MUST ENSURE that care is provided, NOT INSURE.

The Insurance model collects money and finds multiple strategies to prevent the outflow of dollars.  And the INSURANCE model guarantees added expenses taken from the limited community resources.

ENSURING CARE means having providers of medical services collaborate to identify the needs of our patient populations, and then determine cost effective ways to deliver these services.  This is a difficult process and requires a great deal of investment to continually analyze what our patients perceive they need, and matching a realistic offering of services that are most beneficial.  This work is being done through CCNC and the many networks that serve our State.  Our local Network is CCWNC (Community Care Western North Carolina).  I have personally seen the work, and dedication, and UNCOUNTABLE HOURS OF VOLUNTEER TIME invested  BY PHYSICIANS, PHARMACISTS, NURSES, AND OTHER SUPPORT STAFF to develop SYSTEMS OF CARE though the organization that CCWNC  has brought to our community.  This level of collaboration is the envy of other communities who spend as much or more of their limited resources and provide LESS care.  MCOs have had years to do this work, and are not.  MCOs are Insuring the limited flow of resources, not Ensuring care is provided.


A mixed model for Medicaid revenue flow using PLEs and MCOs will take money away from care, but if this is put in place, we need mandated guidelines to be sure that care is Ensured.  Some of these protections have been outlined as a list compiled by thoughtful experts from the NCMS.  This list is included below.


Please be sure to Ensure that individuals who need medical and mental health services are best served and that Insurance costs do not limit care unnecessarily.

Thanks for your time and thoughtfulness,

Harald Kowa, MD

Blue Sky Pediatrics Asheville

828 776-3867


North Carolina Medical Society requests for Medicaid Reform:

  1. Require physicians that participate in NC Medicaid to compose a majority of the governing board of any Medicaid risk-bearing entity.
    • Ensures reform will be a North Carolina-based effort
    • Keeps sound clinical practices at the center of any business decisions
    • Helps protect against out of state MCO’s abandoning NC as in other states
  2. Require any Medicaid risk-bearing entity to utilize a patient centered medical home model as an element of care delivery.
    • Consistent with evidence that PCMH achieves long-term, sustainable savings and quality outcomes
    • Helps ensure that shared-risk/capitation will succeed in joining providers with risk-bearing partners
  3. Require that contracts between the state and risk-bearing entities as well as the risk- bearing entities and providers include concrete, tangible goals regarding cost savings, population health outcomes and patient experience of care.
    • Maintains accountability of risk-bearing entities to taxpayers, policymakers and patients
    • Ensures that any cost savings initiatives are based upon good clinical decision-making and protects patients
  4. Require all Medicaid risk-bearing entities and providers be connected to the health information exchange to ensure the real-time, free flowing exchange of cost and quality data.
    • Ensures that the same data is used across the health care system to drive, measure and compare cost savings and quality
    • A state administered, public utility model provides the most neutral an efficient platform
  5. Require that Medicaid risk-bearing entities be subject to the same patient and provider protections afforded to those in the commercial insurance arena.
    • Creates a consistent set of protections for both public and privately-funded health care systems throughout NC to protect against bad business practices 
    • Prevents healthcare stakeholders from rushing the NCGA for statutory patient protections 
  6. Require that cost saving and efficiency programs currently being utilized are employed during the transition to any new system of care delivery.
    • Maintains cost-saving efforts now in place – preventing surge in costs, decline in quality during transition to reform
    • Eases transition to reform for providers – helping to maintain patient access in Medicaid system during transition