Q: Mr. Crumpton can you describe briefly your background and the business of Caswell Family Medical Center? 

A: Our organization, Caswell Family Medical Center (CFMC), is a federally qualified health center (FQHC).  FQHCs were first introduced in the United States in 1975.  They provide comprehensive primary and preventive care, including oral and mental health, to the underserved in the community and are a critical part of the health care safety net across the country.  There are over 1,100 FQHCs in the United States in operation today, serving over 20 million patients a year.  CFMC was formed as a §501(c)(3) organization in 1978.  CFMC has a single location in Yanceyville, in Caswell County, North Carolina, a rural county with a population of around 24,000.  We currently have a staff of 34 at CFMC. 

Before coming to CFMC, I had the good fortune in 2001 to help start an FQHC in south central Virginia which grew from a staff of two in one location to a staff of 100 in five locations.

Q: Could you please summarize the mission of your organization and the purpose of FQHCs generally?

A: CFMC is organized to ensure access to primary health care and other services for everyone in our community, including the uninsured and underinsured, and low-income individuals.  We offer comprehensive primary care, urgent care and psychiatry and access to specialty services such as cardiology, mammography, nephrology, ob/gyn and behavioral health.  We even arrange indirect health care services such as transportation.  We are a “safety net” for those who cannot afford insurance and for those who have coverage but whose income level will not permit them to access care appropriately. 

While there are other safety net providers in most communities such as those affiliated with State Health Departments and free clinics, most are at or above capacity and do not provide the full range of services which we are committed to making available.  At the end of the day, if we are not there to serve this vulnerable population, hospital emergency rooms would serve as the venue of last resort.

Q: Talk to us for a minute about the financial issues facing CFMC in North Carolina.

A: One concern is while North Carolina has not expanded Medicaid, it is embarking on a Medicaid managed care program where most of the administrative functions will be conducted by private carriers.  Virginia, for example, has operated a Medicaid managed care plan for a number of years, so most of the administrative and payment concerns have been ironed out there.  The North Carolina program is designed to begin in early 2019, and a number of the administrative aspects have not yet gone out for RFP.  Our concerns primarily involve the cash flow issues which can arise from the implementation of a new process and the case management and pre-authorization protocols which may impact delivery and access.

As a FQHC, we are reimbursed by the federal programs under a “cost-based” system, much the way most hospital providers were a couple decades ago.  This favorable reimbursement system provides us with the fiscal capacity to perform a number of functions which are not reimbursed and which otherwise could not be provided.  Under the new Medicaid managed care system, we would be reimbursed by the private carrier contracting with North Carolina based on a negotiated rate, and then we would make a filing with the North Carolina Medicaid program to be reimbursed the difference between the private carrier payment and the cost-based reimbursement we historically received.  Our concern is not whether the reimbursement will be forthcoming; it is the timing of the reimbursement and the impact of the time value of money.  Our margins are very thin, and any interruption to our cash flow can affect our ability to serve our population and to achieve our mission. 

Q: What are some fiscal challenges you face from a federal perspective?

A: As a FQHC, we are obviously dependent on federal funding and are subject to detailed regulations concerning the services we are required to provide.  In recent years, we have faced a “funding cliff” where we suddenly face a significant risk of reductions or elimination of federal resources based on the results of spending bills and threats of government shutdowns.  The recently approved bill appears to hold harmless the FQHCs for the time being; however, this uncertainty makes it very difficult for us to plan how to budget our resources over the coming year and to make appropriate hiring and program decisions.  It also makes it problematic to recruit and retain talented practitioners who are concerned about job stability.

Q: Talk for a minute about the demographics of the population that you serve.

A: As I mentioned earlier, Caswell County has a population of around 24,000, although our catchment area is somewhat broader than the County line.  We are a rural area, and jobs unfortunately are not as plentiful as we would prefer.

In Caswell County, the individuals we serve tend to be the working poor.  They also tend to be elderly.  They are our neighbors and friends and people we know.  Indeed, as with all FQHCs, 51% of our Board of Directors are patients of our program.

Most of our constituents have some coverage, but they lack resources to access health care.  As such, in addition to traditional health care, we help facilitate transportation to CFMC and to other health care resources. 

From a clinical perspective, we focus on providing our clients with a needs assessment.  We offer a full range of primary care services, including ob/gyn.  We also provide important screening exams for breast, colorectal and other cancers.  Lab and radiology services are also an important component.  Finally, opioid and mental health treatment are particularly important in this environment, although we are fortunate to have a smaller opioid problem in Caswell County than in many other rural areas.

Q: What would you like to see from a legislative perspective at the federal and state level?

A: At the federal level, we would hope for a renewed commitment to positioning all FQHCs for success.  A permanent solution for federal funding is extremely important in that regard.  Having to face a fiscal cliff every few years is not an acceptable approach for planning or recruitment, and there are not adequate substitutes for us in the community if we are forced to reduce the level of care and access which we provide.

At the state level, I simply cannot say enough good things about the efforts we see from the new Secretary of Health and Human Services, Mandy Cohen, MD, MPH.  Secretary Cohen seems to have a very clear focus on the issues faced by the population we serve, particularly the behavioral health issues.  I understand that she served as COO and Chief of Staff at CMS and helped it implement a number of marketplace policies.  We are optimistic that she will lead the new North Carolina Medicaid managed care program to success.