The Rest of the Story

Transforming Health and Health Care in North Carolina

Op-Ed from North Carolina Department of Health and Human Services Secretary Rick Brajer
June 10, 2016


From the beginning of his administration, Governor McCrory has been committed to reforming North Carolina Medicaid into a system that puts people first and is centered on patients.

And on June 1st, after nearly three years of discussions with North Carolinians from every corner of our state, and with the participation of more than 2,000 citizens through our public hearing and comment process, we finalized our reform plan and submitted it to the Centers for Medicare and Medicaid Services (CMS).

This is a historic milestone that sets forth our state’s vision for population health improvement in North Carolina. As a result of its clinical, financial and health informatics scale, Medicaid has the potential for driving system-wide transformation toward this vision.

Currently, 20% of all North Carolinians receive Medicaid services. 56% of all children born in our state are born to mothers receiving Medicaid. In total, our Medicaid budget is $14 billion per year.  Clearly, Medicaid is an important commitment by our taxpayers to serve their fellow citizens in need. We have an obligation to make sure financing is sustainable, and we are getting the best health outcomes possible for that investment.

To do so, we will transform health and health care in North Carolina:

  • From paying for how many services patients receive…to paying for improved patient outcomes
  • From focusing on physical health…to clinically integrating physical AND behavioral health
  • From not having flexibility with payments …to having the flexibility to address social, cultural and environmental barriers to health
  • From discontinuing care in families with substance use disorders after their children are placed in foster care…to extending care to those parents to increase the likelihood of family reunification
  • From no financial incentives to providers to transform care…to incentive reform payments tied to quality measures
  • From only the state facing financial risk…to providers sharing responsibility with the state for achieving healthy outcomes

As Secretary, it has been a privilege to meet with and learn from thousands of North Carolinians through this process: beneficiaries, advocates, a wide range of doctors and other clinicians, elected officials, professional associations, EMS personnel, public health department personnel, other safety net providers and leadership at medical schools, residency programs, health systems and commercial plans.

Did our department address all needs and interests of all stakeholders in the June 1 submission?  No. Like virtually all major change initiatives - whether in the public or private sector - we operate within budgetary, operational, regulatory, legal and political constraints. However, we made important revisions between the March 1 draft and the June 1 submission.

So, what’s next?  The pathway to approval will involve discussions between CMS and our Department of Health and Human Services.  Our team is committed to ongoing collaboration with CMS to produce the best results for North Carolinians. We expect this process to take 18 months.  Including preparations for implementation, we expect the process to take three years in total from today.

Meanwhile, we will work on “the foundation” for implementation.  We will work with our partners to define the priorities for improving health and health care of North Carolinians. We will develop the contract framework for prepaid health plans to accomplish transformation goals. We will implement a Health Information Exchange, a secure electronic system where providers will be able to share and view real-time patient health information to improve coordination and care.  And we will put in place a Health Transformation Center to rapidly spread the state’s best quality improvement ideas among clinicians and prepaid health plans.

Most importantly, we will continue to listen to beneficiaries, advocates and stakeholders. They will continue to be invaluable partners in our process of transformation.

Our state has a history of innovating nationally recognized practices in Medicaid. Our Medicaid reform plan builds on that history, advances whole-person centered care, contributes to addressing health disparities in underserved areas of our state, while accelerating system-wide transformation of our health care system for all.

To see a complete copy of the June 1 submission to CMS or to see a summary of all the feedback received through public hearings and submitted comments, please go to

Rick Brajer
North Carolina Department of Health and Human Services

Myths vs Facts: What New York Times, Huffington Post and other media outlets aren't saying about common-sense privacy law

March 25, 2016

1. Does the new bill limit or prohibit private sector companies from adopting their own nondiscrimination policies or practices?
Answer: No. Businesses are not limited by this bill. Private individuals, companies and universities can adopt new or keep existing nondiscrimination policies.

2. Does this bill take away existing protections for individuals in North Carolina?
Answer: No. In fact, for the first time in state history, this law establishes a statewide anti-discrimination policy in North Carolina which is tougher than the federal government’s. This also means that the law in North Carolina is not different when you go city to city.

3. Can businesses and private facilities still offer reasonable accommodations for transgender people, like single occupancy bathrooms for instance?
Answer: Yes. This bill allows and does nothing to prevent businesses, and public or private facilities from providing single use bathrooms.

4. Can private businesses, if they choose, continue to allow transgender individuals to use the bathroom, locker room or other facilities of the gender they identify with, or provide other accommodations?
Answer: Yes. That is the prerogative of private businesses under this new law. For instance, if a privately-owned sporting facility wants to allow attendees of sporting events to use the restroom of their choice, or install unisex bathrooms, they can. The law neither requires nor prohibits them from doing so.

5. Does this law prohibit towns, cities or counties in North Carolina from setting their own nondiscrimination policies in employment that go beyond state law?
Answer: No. Town, cities and counties in North Carolina are still allowed to set stricter non-discrimination policies for their own employees if they choose.

6. Does this bill mean transgender people will always have to use the restroom of the sex of their birth, even if they have undergone a sex change?
Answer: No. This law simply says people must use the bathroom of the sex listed on their birth certificate. Anyone who has undergone a sex change can change their sex on their birth certificate.

7. I’m worried about how this new law affects transgender children or students in North Carolina. Does this bill allow bullying against transgender children in schools?
Answer: Absolutely not. North Carolina law specifically prohibits bullying and harassing behavior against children on the basis of sexual identity.

8. Does this bill affect people with disabilities?
Answer: No. Statewide law also bans discrimination based on disability.

9. Why did North Carolina pass this law in the first place?
Answer: The bill was passed after the Charlotte City Council voted to impose a regulation requiring businesses to allow a man into a women’s restroom, shower, or locker room if they choose. This ordinance would have eliminated the basic expectations of privacy people have when using the rest room by allowing people to use the restroom of their choice. This new local regulation brought up serious privacy concerns by parents, businesses and others across the state, as well as safety concerns that this new local rule could be used by people who would take advantage of this to do harm to others.  In fact, the Charlotte City Council tried to pass this ordinance before but failed, and passed the same ordinance in February of 2016 despite serious concerns from state officials, business leaders and other concerned citizens.

10. What about parents or caregivers bringing children into the restroom?
Answer: The law provides exceptions to young children accompanied by parents or care givers.

11. Will this bill threaten federal funding for public schools under Title IX?
Answer: No, according to a federal court which has looked at a similar issue.

12. Will this bill prevent people from receiving medical attention in an emergency.
Answer: Absolutely not. Nothing will prevent people from receiving medical attention in public or private accommodations.

13. Will this bill affect North Carolina’s ability to create or recruit jobs?
Answer: This bill does not affect companies in North Carolina. North Carolina was one of the top states to do business in the country before this law was passed, and preventing Charlotte’s bathroom ordinance from going into effect on April 1 won’t change that.

14. Why is the state telling cities and towns what it can and can’t do by repealing an ordinance the elected members of the Charlotte City Council passed?
Answer: North Carolina is one of at least 37 states like Virginia where cities and towns cannot pass rules or regulations that exceed the authority given to them by the state. In passing the bathroom ordinance, Charlotte was exceeding its authority and setting rules that had ramifications beyond the City of Charlotte. The legislature acted to address privacy and safety concerns if this ordinance was allowed to go into effect on April 1.

15. Do any other regulations in North Carolina cities, towns or counties come close to what Charlotte was recommending?
Answer: No. Not that we are aware of. Therefore, nothing changes in North Carolina cities, towns and counties, including in Charlotte, regarding discrimination practices and protections now that this law has passed.

16. Did only Republicans vote for this bill?
Answer: No. 11 Democrats voted for this bill in the N.C. House of Representatives and no Democratic Senators voted against it. In fact, Democratic Senators walked out to avoid voting on the issue at all because many were going to vote for it and they did not want show their division.

17. Why did the Legislature call a special session to overturn the bathroom ordinance?
Answer: The new Charlotte ordinance, which would have required all businesses to change their restroom policies and take away the expectation of privacy people have when using the restroom, was going to go into effect on April 1 if no action was taken.

18. Is North Carolina at a disadvantage when it comes to recruiting jobs because it does not have ordinances like the one Charlotte was proposing?
Answer: No. In fact in the last 3 years without an ordinance like this, North Carolina has created the 6th most jobs in the country – over 260,000 net new jobs. We know of no examples of companies being recruited to North Carolina that have asked if the state has an ordinance like the one Charlotte was proposing.


State lifts “do not drink” recommendations

March 7, 2016

Fact Sheet on Water Use Recommendations

Today state health officials lifted the “do not drink” recommendations that were associated with health risk evaluations for private wells showing higher levels of two elements – hexavalent chromium and vanadium - tested as part of the Coal Ash Management Act.

The water deemed safe in these wells is as safe as the majority of public water supplies in the country. All public water systems are required to meet or exceed federal standards for safe drinking water.

This update is the result of a very purposeful approach taken by DHHS after being asked to issue health risk evaluations on elements for which few standards exist.

From the beginning, DHHS has committed to studying these elements, gaining deeper knowledge of their risks to people’s health and of communicating with concerned well owners throughout the process.

Recognizing that hexavalent chromium and vanadium are associated with potential health risks, the department made very cautious recommendations in the beginning, to allow time for further study and information to be gained.

Since that time, state health officials have:

  • Been actively engaged in further analysis of the health risks of each of these elements
  • Studied other states’ ongoing regulations, as well as the federal Environmental Protection Agency’s work in this area, and have learned that there are no trends for increasing regulations on these elements in the past year
  • Received a report on March 1, 2016, from the Department of Environmental Quality on vanadium and hexavalent chromium that has analyzed these elements in other sources of drinking water.

Throughout this process, DHHS has communicated with well owners, sending a letter in October to make them aware that the research is continuing.

After receiving the DEQ report March 1 and with the benefit of this additional knowledge, DHHS announced on March 7 that state health officials are lifting the “do not drink” recommendations.

“We have been committed to a process of further study and ongoing communication,” said State Health Director Randall Williams, MD. “We believe lifting these recommendations reflects the current state of our knowledge on the health risks of these elements and aligns them with other users of water with similar levels in North Carolina.”


Advancements in the Office of Chief Medical Examiner

November 23, 2015

85,212 people died in North Carolina in 2014 and the North Carolina Medical Examiner System conducted 11,302 investigations and performed 3,882 autopsies during that year. The Office of the Chief Medical Examiner in North Carolina is committed to investigating deaths deemed to be in the public interest and governed by stature. Our goal is to help all citizens of North Carolina by assisting the criminal justice, civil justice and public health systems. We are further aware that we often deal with families and friends at a time of great loss and are committed to helping them during this time. The present system was created in 1967 by an act of the General Assembly. Subsequent General Assembly Study Groups in 2001 and 2014 provided recommendations so that the OCME office was able to issue its April 1, 2015, Report on Achieving National Accreditation for the North Carolina Office of the Chief Medical Examiner. We move toward this goal intentionally and with great purpose to meet the needs of a growing state and to always strive to improve our service to citizens of North Carolina. With the signing of the state budget on September 18, 2015, by Governor McCrory, in addition to ongoing quality improvement, markers of improvement in the office of the Chief Medical Examiner include:

  • January 2015 – All forensic pathologists throughout North Carolina are performing less than 250 autopsies per year in 2014 which meets National Association of Medical Examiners NAME standards.
  • February 2015 – Hiring of Public Health Epidemiologist for OCME’s office to compile data including an annual report as per NAME standards.
  • April 2015 – National Accreditation of North Carolina’s Toxicology Lab in Raleigh which performs all toxicology tests for the entire state and is required by NAME.
  • May 2015 – Hiring of a Training Coordinating Specialist and required attendance at annual regional seminars to standardize training in all 100 counties of 450 Local Medical Examiners approved by the Chief Medical Examiner.
  • June 2015 – Hiring of Deputy Chief Medical Examiner bringing total of 16 Board Certified forensic pathologists regionalized in four centers spread throughout the state (Raleigh, Charlotte, Winston Salem and Greenville) to achieve full staffing. All of these forensic pathologists belong to the National Association of Medical Examiners with two on the Board of Directors and two presenting and one moderating at the recent national convention in Charlotte. In addition, the Deputy Secretary of Health Services is a member of NAME. There are only about 500 board certified forensic pathologists in the entire United States. We continue to perform a small percentage of autopsies at five other sites in state but have moved medicolegal autopsies to four regional centers to be performed by forensic pathologists.
  • September 2015 – With funding from General Assembly, by having academic affiliation at three of the state’s sites, there will be a constant emphasis on training of fellows in forensic pathology which allows us to maintain excellence by teaching best practices in the performance of autopsies. In addition, all second-year medical students at UNC-Chapel Hill and residents from Duke, ECU, UNC-CH and Wake Forest Baptist Medical Center receive training at the state’s institutions. Recent legislation approved fellows for ECU and Wake Forest Baptist. Our hope is that these fellows will help us meet future work force issues.
  • September 2015 – General Assembly authorizes funding for Electronic Death Registration System to expedite the release of death certificates.
  • September 2015 – Funding from General Assembly authorizes increase of fees paid to Local Medical Examiners, pathologists and for transportation.
  • October 2015 – Recruiting of a Family Support Specialist to answer families’ and others questions about preliminary findings before a final autopsy report is filed which may be awaiting lab tests. This person also is a resource for families as they grieve and helps them navigate to resources available to them.
  • October 2015 – Recruiting of an Agency Legal Specialist to decrease administrative duties of the forensic pathologists.

Ongoing challenges as we move forward:

  • Turn-around time for final reports which we are constantly monitoring and believe will improve now that we are fully staffed with 16 forensic pathologists.
  • Standardization of Local Medical Examiners training and death scene investigation in all 100 counties. The newly required training program will improve this. Surveys of other states reveal a diversity of approaches to this aspect of investigation. A site visit to learn from Maryland’s Medical Examiner system is part of our quality improvement.
  • New facilities in regional centers and another new regional center to meet the growing population in North Carolina.
  • Future funding requests to fulfill all requirements for NAME accreditation.

We have a great appreciation for how important these services are to the people of North Carolina and a sensitivity for them at times of loss and remain committed to helping people during this time.