2004CCNCCCNC

“ Improving Medicaid Quality and Controlling Costs by Building Community Systems of Care”

“ Improving Medicaid Quality and Controlling Costs by Building Community Systems of Care”

L. Allen Dobson ,Jr. MD FAAFPAssistant Secretary NC Department of Health &Human Services

L. Allen Dobson ,Jr. MD FAAFPAssistant Secretary NC Department of Health &Human Services

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2004CCNCCCNC

Greetings from Governor Mike Easley, Secretary Carmen Hooker-Odom and your colleagues in NC

Greetings from Governor Mike Easley, Secretary Carmen Hooker-Odom and your colleagues in NC

2004CCNCCCNC

Major Department GoalsMajor Department Goals

Medicaid Reform ( CCNC) Mental Health Reform Health Disparities MMIS change- NC Leads

Vision: Innovation and Collaboration

Medicaid Reform ( CCNC) Mental Health Reform Health Disparities MMIS change- NC Leads

Vision: Innovation and Collaboration

2004CCNCCCNC

Current NC Medicaid FactsCurrent NC Medicaid Facts1.6 million unduplicated eligibles covered (15.2% 0f

population)810,000 children covered45% of all babies born covered30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%Physicians account for only 9-10% of costs!!!Over $1.5 billion spend on mental health servicesTotal budget over $ 8.5 billion

1.6 million unduplicated eligibles covered (15.2% 0f population)

810,000 children covered45% of all babies born covered30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%Physicians account for only 9-10% of costs!!!Over $1.5 billion spend on mental health servicesTotal budget over $ 8.5 billion

2004CCNCCCNC

Improving Quality&

Controlling Medicaid Costs

Improving Quality&

Controlling Medicaid Costs

Developing Community Care of NC

Why It Was Needed?

Developing Community Care of NC

Why It Was Needed?

2004CCNCCCNC

Why We Started CCNC as PilotWhy We Started CCNC as Pilot NC is a mainly rural state not well suited for and with

little managed care Successful Carolina Access program linked

recipients with PCP in all 100 counties PCCM model alone not effective in cost control Little efforts around quality State was piloting Managed Care program in 2 metro

areas- needed alternative

NC is a mainly rural state not well suited for and with little managed care

Successful Carolina Access program linked recipients with PCP in all 100 counties

PCCM model alone not effective in cost control Little efforts around quality State was piloting Managed Care program in 2 metro

areas- needed alternative

2004CCNCCCNC

ISSUES: No real care coordination system at the local level

Providers feel limited in their ability to manage care in current system

Local public health departments and area mental health services are not coordinated with the medical care system

Duplication of services at the local level State “Silo Funding”

2004CCNCCCNC

Primary GoalsPrimary Goals

Improve the quality of care provided to the Medicaid population while controlling costs

Develop Community based networks capable of managing populations

Fully Develop the Medical Home Model

Improve the quality of care provided to the Medicaid population while controlling costs

Develop Community based networks capable of managing populations

Fully Develop the Medical Home Model

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2004CCNCCCNC

Community Care of North CarolinaCommunity Care of North Carolina

Joins other community providers (hospitals, health departments and departments of social services) with physicians

Designated medical home

Creates community networks that assume responsibility for managing recipient care

Joins other community providers (hospitals, health departments and departments of social services) with physicians

Designated medical home

Creates community networks that assume responsibility for managing recipient care

Build on ACCESS I (PCCM) 1998-99 as pilot program

Build on ACCESS I (PCCM) 1998-99 as pilot program

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2004CCNCCCNC

1999

Community Care of North Carolina (Access II and III Networks)

Then

2004CCNCCCNC

Community Care of North CarolinaNow in 2007Community Care of North CarolinaNow in 2007

Focuses on improved quality, utilization and cost effectiveness of chronic illness care

15 Networks with more than 3500 Primary Care Physicians (1000 medical homes)

over 750,000 enrollees

Focuses on improved quality, utilization and cost effectiveness of chronic illness care

15 Networks with more than 3500 Primary Care Physicians (1000 medical homes)

over 750,000 enrollees

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2004CCNCCCNC

AccessCare Network SitesAccessCare Network CountiesAccess II Care of Western NCAccess III of Lower Cape Fear

Southern Piedmont Community Care Plan

Community Care Plan of Eastern NC

Community Health Partners Northern Piedmont Community Care

Partnership for Health Management

Sandhills Community Care Network

Community Care of Wake and Johnston Counties

CCNC Spread: 15 networks, 3500 MDs, >750,000 patientsCCNC Spread: 15 networks, 3500 MDs, >750,000 patients

CCNC Networks as of November 2006CCNC Networks as of November 2006

Carolina Collaborative Comm. CareCarolina Community Health Partnership

Comm. Care Partners of Gtr. MecklenburgNorthwest Community Care Network

Central Care Health Network

2004CCNCCCNC

Community Care Networks: Community Care Networks: Non-profit organizations Includes all providers including safety net

providers Steering/Governance committee Medical management committee Receive $2.50 PM/PM from the State Hire care managers/medical management staff PCP also get $2.50 PMPM to serve as medical

home and to participate in DM

Non-profit organizations Includes all providers including safety net

providers Steering/Governance committee Medical management committee Receive $2.50 PM/PM from the State Hire care managers/medical management staff PCP also get $2.50 PMPM to serve as medical

home and to participate in DMHOME

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2004CCNCCCNC

Each Network Now Have:Each Network Now Have:

Part- time paid Medical Director- role is oversight of quality efforts, meets with practices and serves on State Clinical Directors Committee

Clinical Coordinator- oversees the overall network operations

Care Managers- small practices share/large practices may have their own assigned

PharmD to assist with medication management of high cost patients

Part- time paid Medical Director- role is oversight of quality efforts, meets with practices and serves on State Clinical Directors Committee

Clinical Coordinator- oversees the overall network operations

Care Managers- small practices share/large practices may have their own assigned

PharmD to assist with medication management of high cost patients

2004CCNCCCNC

What Networks DoWhat Networks Do Assume responsibility for Medicaid recipients

Implement improved care management and disease management systems ( rapid cycle QI)

Identify costly patients and costly services

Develop and implement plans to manage utilization and cost

Create the local systems to improve care & reduce variability

Assume responsibility for Medicaid recipients

Implement improved care management and disease management systems ( rapid cycle QI)

Identify costly patients and costly services

Develop and implement plans to manage utilization and cost

Create the local systems to improve care & reduce variability

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2004CCNCCCNC

Keys to SuccessKeys to Success Medical and administrative committees that provide

direction on care management activities. Dedicated case managers to carry out such population

management activities as risk assessment, case management, and disease management.

Care management processes that apply both new and existing resources, such as health department support services, in meeting the needs of enrollees.

Regular reporting and profiling of target initiatives that allow networks to monitor their progress in achieving target goals.

Medical and administrative committees that provide direction on care management activities.

Dedicated case managers to carry out such population management activities as risk assessment, case management, and disease management.

Care management processes that apply both new and existing resources, such as health department support services, in meeting the needs of enrollees.

Regular reporting and profiling of target initiatives that allow networks to monitor their progress in achieving target goals.

2004CCNCCCNC

Guidelines for Selecting a Quality Improvement Initiative Guidelines for Selecting a Quality Improvement Initiative There are enough Medicaid enrollees with the disease to obtain

a "return on investment." Evidence exists that best practices lead to predictable and

improved outcomes. Appropriate evidence-based practice guidelines are available. Best practices and outcomes are measurable, reliable, and

relevant. There is room for improvement - a gap exists between best

practice and everyday practice. There is a measurable baseline and thus an ability to measure

improvement.

There are enough Medicaid enrollees with the disease to obtain a "return on investment."

Evidence exists that best practices lead to predictable and improved outcomes.

Appropriate evidence-based practice guidelines are available. Best practices and outcomes are measurable, reliable, and

relevant. There is room for improvement - a gap exists between best

practice and everyday practice. There is a measurable baseline and thus an ability to measure

improvement.

Physicians must be supportive

2004CCNCCCNC

Current State-wide Disease and Care Management Initiatives

Current State-wide Disease and Care Management Initiatives

Asthma Diabetes Pharmacy Management ( PAL, NH poly-

pharmacy) Dental Screening and Fluoride Varnish Emergency Department Utilization

Management Case Management of High Cost – High Risk Congestive Heart Failure (CHF) (2006)

Asthma Diabetes Pharmacy Management ( PAL, NH poly-

pharmacy) Dental Screening and Fluoride Varnish Emergency Department Utilization

Management Case Management of High Cost – High Risk Congestive Heart Failure (CHF) (2006)

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LASTRapid Cycle Quality ImprovementRapid Cycle Quality Improvement

2004CCNCCCNC

Network Specific Quality Improvement InitiativesNetwork Specific Quality Improvement Initiatives

“Assuring Better Child Development” (ABCD) ADD/ADHD HCAP/Coordinated care for the uninsured Gastroenteritis (GE) Otitis Media (OM) Projects with Public Health (Low Birth Weight, open

access & diabetes self management) Diabetes Disparities Medical Home/ED Communications

“Assuring Better Child Development” (ABCD) ADD/ADHD HCAP/Coordinated care for the uninsured Gastroenteritis (GE) Otitis Media (OM) Projects with Public Health (Low Birth Weight, open

access & diabetes self management) Diabetes Disparities Medical Home/ED Communications

2004CCNCCCNC

New Network PilotsNew Network Pilots

Aged, Blind and Disabled ( ABD) Depression Screening and Treatment Mental Health Integration Mental Health Provider Co-location E- Rx Medical Group Visits Dually Eligible Recipients

Aged, Blind and Disabled ( ABD) Depression Screening and Treatment Mental Health Integration Mental Health Provider Co-location E- Rx Medical Group Visits Dually Eligible Recipients

2004CCNCCCNC

Asthma and Diabetes InitiativesAsthma began 1998 Diabetes began 2000

Asthma and Diabetes InitiativesAsthma began 1998 Diabetes began 2000

Adopted nationally accepted best practice guidelines

Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level

Adopted nationally accepted best practice guidelines

Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level

2004CCNCCCNC

Diabetes MeasuresDiabetes Measures Diabetic Flow Sheet in use on the medical record Continued care visits at least 2 x year Blood pressure at every continuing care visit Referral for dilated eye / retinal exam every year Foot exam every year Monofilament / sensory exam every year Glycosylated Hemoglobin (HgbA1c) at least 2 in 12 months Annual Lipid profile Annual Flu Vaccine Pneumococcal vaccine done once (repeat IF first dose was

given at <65 yrs. old AND pt. is now >65 AND first dose was given > 5 yrs ago)

Diabetic Flow Sheet in use on the medical record Continued care visits at least 2 x year Blood pressure at every continuing care visit Referral for dilated eye / retinal exam every year Foot exam every year Monofilament / sensory exam every year Glycosylated Hemoglobin (HgbA1c) at least 2 in 12 months Annual Lipid profile Annual Flu Vaccine Pneumococcal vaccine done once (repeat IF first dose was

given at <65 yrs. old AND pt. is now >65 AND first dose was given > 5 yrs ago)

2004CCNCCCNC

Key ResultsKey Results

Asthma 34% lower hospital admission rate 8% lower ED rate average episode cost for children enrolled in

CCNC was 24% lower 93% received appropriate inhaled steroidDiabetes 15% increase in quality measures

Asthma 34% lower hospital admission rate 8% lower ED rate average episode cost for children enrolled in

CCNC was 24% lower 93% received appropriate inhaled steroidDiabetes 15% increase in quality measures

2004CCNCCCNC

Gathering and Sharing the ResultsGathering and Sharing the Results

Utilizing claims data Chart Audits (contract with NC AHEC) Practice profiles

Utilizing claims data Chart Audits (contract with NC AHEC) Practice profiles

2004CCNCCCNC

Community Care of North CarolinaDiabetes Disease Management Quality Initiative

Round 5 2005

Distribution of HbA1c Values

45% 46%52%

46% 45% 44% 45%37%

51%41% 40%

49%55%

38%

21% 20%18%

17% 21% 21% 23%

19%

18%

20% 19%

18%17%

15%

14% 13% 10%

12%13% 14% 11%

13%

10%

12% 14%9%

13%

18%

8% 8% 6%9%

8% 10% 7%

9%

8%12% 11% 6%

8%12% 13% 14% 16% 13% 11% 13%

22%13% 15% 16% 17%

7%14%

14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HbA1c Range

% o

f P

ati

en

ts w

ith

in e

ach

Hb

A1c R

an

ge

< 7.0 7.0 - 8.0 8.0 - 9.0 9.0 - 10.0 > 10.0

2004CCNCCCNC

Cost/Benefit EstimatesCost/Benefit Estimates

2004CCNCCCNC

Cost Savings for SFY 2004July 1, 2003- June 30, 2004

Cost Savings for SFY 2004July 1, 2003- June 30, 2004

Cost - $10.2 million

(cost of CCNC operations)

Savings- $124 million compared to SFY 03 Savings $225 million compared to FFS

SFY 2005 and 2006 final results pending but similar results

Cost - $10.2 million

(cost of CCNC operations)

Savings- $124 million compared to SFY 03 Savings $225 million compared to FFS

SFY 2005 and 2006 final results pending but similar results

2004CCNCCCNC

Cabarrus County- 4 Year ResultsCabarrus County- 4 Year Results

4 5 0

5 0 0

5 5 0

6 0 0

S F Y 0 1 S F Y 0 2 S F Y 0 3 S F Y 0 4 S F Y 0 5

C a b a r r u s

R o w a n

# R E F !

S t a t e w id e T o t a l

% Change      

SF02 SF03 SF04 SF05 4 yr

-1% -7% 2.90% 1.67% -3%

6% 0% 4.30% 7.00% 17%

5% 0% 5.30% 7.00% 17%

Cabarrus

Rowan

State

2004CCNCCCNC

Our Plan for Further System Change

Our Plan for Further System Change

Governor’s Quality Initiative ( BCBC, SEHP, Medicaid & Medicare and other major insurers)- over 85% of NC insured included

NC Health Net (coordinated free care) Mental Health Transformation/Integration Medicare 646 Redesign Waiver

Governor’s Quality Initiative ( BCBC, SEHP, Medicaid & Medicare and other major insurers)- over 85% of NC insured included

NC Health Net (coordinated free care) Mental Health Transformation/Integration Medicare 646 Redesign Waiver

2004CCNCCCNC

Want to Know More?Want to Know More?

www.communitycarenc.comwww.communitycarenc.com

2004CCNCCCNC

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