North Carolina: First in Flight, Second in Patient Centered Recognition…42nd in Public Health Spending
By Heather Rothrock, MBA, PCMH-CCE
When it comes to things like flight and patient-centered recognition, the state of North Carolina (NC) has proved itself ahead-of-the-curve. Back in December 1903 in Kitty Hawk, a 12-second-long flight in an aircraft created and manned by Orville and Wilbur Wright served as the first sustained flight in the aviation race of the early 1900’s, landing NC the “First in Flight” accolade.
Fast forward to 2019, a combination of 823 Patient-Centered Medical Homes and 94 Patient-Centered Specialty Practices places NC 2nd in the nation, leading in the nation for the number of practices recognized by the National Committee for Quality Assurance (NCQA) across these two patient-centered programs.
However, when it comes to public health spending, the State hasn’t matched their other successes. Dedicating just $57 per person to public health (based on State dollars dedicated to public health and federal dollars directed to states by the CDC and HRSA), NC ranks 42nd in the nation, falling below the national average of $86 per person and significantly trailing 1st place, Alaska, at $281 per person.
Though this ranking may not receive the same attention as the state’s more positive claims to fame, the impact of this lack in public health spending is extensive. Evidence supports that many public health interventions save money. Examples like tobacco control initiatives, immunization, cardiovascular disease prevention, and workplace health promotion programs are often more cost-effective than private or personal health care interventions.
This measure is also only one of the 35 core measures contributing to NC’s national ranking of 33rd in overall health status for 2017 and 2018, according to a compilation by America’s Health Rankings (a service of the United Health Foundation). This report builds on the World Health Organization’s definition of health, using a combination of four categories of health determinants—behaviors, community & environment, policy, and clinical care—and a fifth category influenced by these health outcomes. Other than the Behaviors category (ranked 22nd), NC ranks in the bottom half across the other four domains. Since health rankings were first published by this group in 1990, NC has never moved above 31st place (2015), though fortunately, has never dropped lower than 41st (1993), as shown in the chart below.
In addition to public health spending, other noteworthy measures evaluated in this set and contributing to NC’s position include challenges like a high incidence of Chlamydia, at 577.6 cases per 100,000 population (ranked 45th), a high prevalence of low birthweight, at 9.2% of live births (ranked 43rd and followed closely by a 41st rank in infant mortality), and finally, a high percentage of uninsured population, at 10.6% (ranked 42nd).
Though there is certainly improvement to be made on the whole, NC does boast a high percentage of high school graduation at 85.9% of students (ranked 22nd), high HPV immunization coverage among adolescent males at 53.7% (ranked 10th), and a low prevalence of excessive drinking at 16.9% of adults (ranked 14th). NC has also greatly reduced the percentage of adults who smoke from 21.1% in 2012 to 17.1% in 2018. The state is joined in the category of significant smoking reduction (>18% change) by Hawaii, which occupies the number 1 seed in overall health.
NC has been applauded at a national level for efforts to reduce prescription opioid misuse through the launch of Project Lazarus in 2007. Despite the many successes of this program, drug deaths have actually increased by 25% over the past three years from 13.0 to 16.2 deaths per 100,000 population (ranked 22nd). This figure is not exclusive to NC, as we share in this statistic nationally with matching 25% increases, illustrative of the national drug crisis and its fatal consequences.
As an effort toward improvement, we at Emtiro Health often highlight the importance of practices pursuing programs like patient-centered medical home (PCMH) and patient-centered specialty practice (PCSP) in order to see gains in areas including access, care coordination, care management, and performance improvement. The benefits of these programs are undeniable, but delivery transformation is only one piece of the larger health improvement pie. A noticeable improvement for NC (and for the United States in general) goes beyond individual providers making positive changes in their own practices: the impetus lies more heavily on creating an effective system of care overall, with cornerstones founded in (but not limited to) population-focused solutions, addressing social determinants of health, expanding access to insurance, and expanding access to providers.
NC gets at some of these cornerstones through several well-established initiatives like Healthy North Carolina 2020, a decennial effort aimed at mobilizing the state to achieve a common set of health objectives, thereby improving the health status of every North Carolinian. Striving to achieve objectives outlined in this program has led to successes like decreasing heart attack rates, reducing infant mortality, reducing unintentional poisoning, establishing multiple farmer’s markets and community gardens, and a variety of tobacco control efforts.
Another initiative in NC, the Healthy Opportunities pilot, focuses on tackling Social Determinants of Health (SDOH) as fundamental drivers of health through strategies like the development of a standardized set of SDOH screening questions, building NCCARE360 as an electronic resource to connect identified needs with community resources, and streamlining cross-enrollment in key benefit programs.
On the topic of expanding access, NC is one of just 14 remaining states choosing not to expand Medicaid. It is estimated that expanding Medicaid would increase coverage for roughly 626,000 people and reduce our uninsured rate by 4.2%, perhaps also moving us up from the aforementioned unfavorable position nationally in uninsured population.
Seeing how we stack up nationally can be eye-opening, especially as our legislature continues to disagree on Medicaid expansion in the wake of overhauling our existing Medicaid system. Being armed with knowledge will be critical in moving us forward as the landscape changes, both specific to Medicaid and generally as we shift to a more value-based care environment. NC secured a solid reputation in the runway for aviation, no less important is the health of NC residents and the system within which they receive care.