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2004CCNCCCNC
“ Improving Medicaid Quality by
Building Community Systems of
Care”
“ Improving Medicaid Quality by
Building Community Systems of
Care”
L. Allen Dobson ,Jr. MD FAAFPAssistant SecretaryNC Department of Health &
Human Services
L. Allen Dobson ,Jr. MD FAAFPAssistant SecretaryNC Department of Health &Human Services
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2004CCNCCCNC
Major Depar t m ent GoalsMajor Depar t m ent 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
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2004CCNCCCNC
The Cost Equat ionThe Cost Equat ion
Eligibility and Benefits - who you cover andwhat you cover
Reimbursement - what you pay Utilization - how much services are provided
We just have to figure out how to manage utilization!!!
Eligibility and Benefits - who you cover andwhat you cover
Reimbursement - what you pay Utilization - how much services are provided
We just have to figure out how to manage utilization!!!
Eligibility/Benefits + Reimbursement Rate + Utilization = Cost
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2004CCNCCCNC
Current NC Medic a id Fac t sCurrent NC Medic a id Fac t s
1.2 million unduplicated eligibles covered (15.2% 0f
population)686,000 children covered
45% of all babies born covered
30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%
Physicians account for only 9-10% of costs!!!
Over $1 billion spend on mental health services
Total budget over $ 9 billion
1.2 million unduplicated eligibles covered (15.2% 0f
population)686,000 children covered
45% of all babies born covered
30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%
Physicians account for only 9-10% of costs!!!
Over $1 billion spend on mental health services
Total budget over $ 9 billion
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2004CCNCCCNC
Im prov ing Qual i t y
&
Cont ro l l ing Medic a id Cost s
Im prov ing Qual i t y
&
Cont ro l l ing Medic a id Cost s
Developing Community Care of NCDeveloping Community Care of NC
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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 healthservices are not coordinated with the medical care
system
• Duplication of services at the local level
• State “Silo Funding”
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2004CCNCCCNC
Pr im ary Goals o f Medic a idEffor tPr im ary Goals o f Medic a idEffor t
Improve the care of the Medicaid population while controlling costs
Develop Community based networks capable
of managing populations
Improve the care of the Medicaid population while controlling costs
Develop Community based networks capable
of managing populations
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2004CCNCCCNC
Basic Operat ing Prem iseBasic Operat ing Prem ise Regardless of who manages Medicaid, the hospitals,
physicians and safety net providers in NC servingpatients remain the same and must be engaged
We need to transform state Medicaid managementfrom a regulatory function to a health caremanagement function
We must carefully balance cost containment withquality improvement efforts
Decision making must be driven by data & outcomesmonitored
We must help transform healthcare system fromacute care model to chronic illness model
Regardless of who manages Medicaid, the hospitals,physicians and safety net providers in NC servingpatients remain the same and must be engaged
We need to transform state Medicaid managementfrom a regulatory function to a health caremanagement function
We must carefully balance cost containment withquality improvement efforts
Decision making must be driven by data & outcomes
monitored We must help transform healthcare system from
acute care model to chronic illness model
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2004CCNCCCNC
Com m uni t y Care o f Nor t h Caro l inaCom m uni t y Care o f Nor t h Caro l inaBu il d on ACCESS I (PCCM) 1998-99 as
pi lo t program
Bu il d on ACCESS I (PCCM) 1998-99 aspi lo t program
Joins other community providers (hospitals,health departments and departments of social
services) with physicians
Creates community networks that assume
responsibility for managing recipient care
Joins other community providers (hospitals,health departments and departments of social
services) with physicians
Creates community networks that assume
responsibility for managing recipient care
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2004CCNCCCNC
1999
Community Care of North Carolina (Access II and III Networks)
Then
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2004CCNCCCNC
Com m uni t y Care o f Nort h Caro l inaNow in 2006 Com m uni t y Care o f Nor t h Caro l inaNow in 2006
Focuses on improved quality, utilization andcost effectiveness of chronic illness care
15 Networks with more than 3500 PrimaryCare Physicians (medical homes)
over 715,000 enrollees
Focuses on improved quality, utilization andcost effectiveness of chronic illness care
15 Networks with more than 3500 PrimaryCare Physicians (medical homes)
over 715,000 enrollees
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2004CCNCCCNC
AccessCare Network Sites
AccessCare Network Counties
Access II Care of Western NC
Access III of Lower Cape Fear
Southern Piedmont Community Care Plan
Community Care Plan of Eastern NC
Community Health Partners
Northern Piedmont Community CarePartnership for Health Management
Sandhills Community Care Network
Community Care of Wake and Johnston Counties
Com m uni t y Care o f Nor t h Caro l inaCom m uni t y Care o f Nor t h Caro l inaCCNC Net w ork s asof J u ly 2006CCNC Net w ork s asof Ju ly 2006
Carolina Collaborative Comm. Care
Carolina Community Health Partnership
Comm. Care Partners of Gtr. Mecklenburg
Central Piedmont Access II
Central Care Health Network
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2004CCNCCCNC
Com m uni t y Care Net w ork s :Com m uni t y Care Net w ork s :
Non-profit organizations
Includes all providers including safety netproviders
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 medicalhome and to participate in DM
Non-profit organizations
Includes all providers including safety netproviders
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 medicalhome and to participate in DM
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2004CCNCCCNC
What Net w ork s DoWhat Net w ork s Do Assume responsibility for Medicaid recipients
Identify costly patients and costly services
Develop and implement plans to manage
utilization and cost Create the local systems to improve care & reduce
variability
Implement improved care management anddisease management systems
Assume responsibility for Medicaid recipients
Identify costly patients and costly services
Develop and implement plans to manage
utilization and cost Create the local systems to improve care & reduce
variability
Implement improved care management anddisease management systems
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2004CCNCCCNC
Guide l ines for Se lec t ing aQual i t y Im provem ent In i t ia t i veGuide l ines for Se lec t ing aQual i t y Im provem ent In i t ia t i ve There are enough Medicaid enrollees with the disease to
obtain a "return on investment." Evidence exists that best practices lead to predictable andimproved 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 andimproved 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
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2004CCNCCCNC
Current St at e-w ide Disease andCare Managem ent In i t ia t ives
Current St at e-w ide Disease andCare Managem ent In i t ia t ives
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)HOME
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LAST Rapid Cycle Quality Improvement Rapid Cycle Quality Improvement
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2004CCNCCCNC
Net w ork Spec i f i c Qual i t yIm provem ent In i t i at i ves
Net w ork Spec i f i c Qual i t yIm provem ent In i t i at i ves
“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, openaccess & 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, openaccess & diabetes self management)
Diabetes Disparities
Medical Home/ED Communications
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2004CCNCCCNC
New Net w ork Pi lo t sNew Net w ork Pi lo t s
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
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2004CCNCCCNC
Ast hm a and Diabet es Ini t ia t i vesAst hm a began 1998 Diabet es began 2000
Ast hm a and Diabet es Ini t ia t i vesAst hm a began 1998 Diabet es began 2000
Adopted nationally accepted best practiceguidelines
Physicians set performance measures Provide regular monitoring and feedback
Implement CQI at practice level
Adopted nationally accepted best practiceguidelines
Physicians set performance measures Provide regular monitoring and feedback
Implement CQI at practice level
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2004CCNCCCNC
Ast hm a MeasuresAst hm a Measures
Percentage of asthma patients staged
Percentage of asthma patients staged II, III,and IV on maintenance medications
Percentage of asthma patients with a writtenAsthma Management Plan
Percent of asthma patients receiving anannual influenza vaccine
Percentage of asthma patients staged
Percentage of asthma patients staged II, III,and IV on maintenance medications
Percentage of asthma patients with a writtenAsthma Management Plan
Percent of asthma patients receiving anannual influenza vaccine
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2004CCNCCCNC
Asthm a In i t i a t i veAs thm a In i t i a t i ve
K eyK ey
Process MeasuresProcess Measures
47%
56%
64%64%
52%49%
93%95%92%93%
67%
78%75%73%
68%
0%
20%
40%
60%
80%
100%
'99 '00 '01 '02 '03 '99 '00 '01 '02 '03 '99 '00 '01 '02 '03
47%
56%
64%64%
52%49%
93%95%92%93%
67%
78%75%73%
68%
0%
20%
40%
60%
80%
100%
'99 '00 '01 '02 '03 '99 '00 '01 '02 '03 '99 '00 '01 '02 '03
1 2 3
1 % with asthmawho haddocumentationof staging
% with asthmawho haddocumentationof staging
2 % staged II – IVon inhaledcorticosteroids
% staged II – IVon inhaledcorticosteroids
3 % staged II – IVwho have an AAP
% staged II – IVwho have an AAP
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2004CCNCCCNC
K ey Resu lt sK ey Resu lt s
Asthma
18% lower hospital admission rate for enrollees under21 than in the control group, and an 26% lower EDrate than in the control group the average episodecost for children enrolled in CCNC was 24% lower
than those not enrolled in the program (CCNC costper episode = $687 versus $853)
93% received appropriate inhaled steroid
21% increase in the number of patients with asthmawho have been staged and a 112% increase in thenumber of asthmatic patients receiving flu vaccines
Asthma
18% lower hospital admission rate for enrollees under21 than in the control group, and an 26% lower EDrate than in the control group the average episodecost for children enrolled in CCNC was 24% lower
than those not enrolled in the program (CCNC costper episode = $687 versus $853)
93% received appropriate inhaled steroid
21% increase in the number of patients with asthmawho have been staged and a 112% increase in thenumber of asthmatic patients receiving flu vaccines
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2004CCNCCCNC
0
5
10
15
2 0
A s t h m a E D R a t e p e r 1 , 0 0 0 M e m b e r
M o n t h s
CCNC Asthma ED Rates for FY2003 and FY2005
Rate 16 .3 3 12 .0 8
FY0 3 ED Ra te FY 05 ED Ra te
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2004CCNCCCNC
0
1
2
3
4
5
A s t h m a I P R a t e p
e r 1 , 0
0 0 M e m b e r
M o
n t h s
CCNC Asthma Inpatient Rates for FY2003 and FY2005
Rate 4.04 3.3
FY03 IP Rate FY05 IP Rate
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2004CCNCCCNC
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Percent Reduction in Asthma ED and Inpatient Admissions
Between FY2003 and FY2005
Percent 26.03% 18.32%
Reduction in ED Rate Reduction in IP Rate
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2004CCNCCCNC
Diabet es MeasuresDiabet es 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 12months
Annual Lipid profile
Annual Flu Vaccine Pneumococcal vaccine done once (repeat IF first dosewas given at <65 yrs. old AND pt. is now >65 AND firstdose 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 12months
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 firstdose was given > 5 yrs ago)
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2004CCNCCCNC
Diabet es In i t ia t iveProc ess MeasuresDiabet es In i t ia t iveProc ess MeasuresCommunity Care of NC Diabetes Quality Initiative Summary (Established)Community Care of NC Diabetes Quality Initiative Summary (Established)
Baseline 2001Baseline 2001 R1 2002R1 2002 R2 2002R2 2002 R3 2003R3 2003 R4 2004 R5 2005R4 2004 R5 2005
0
10
20
30
40
50
6070
80
90
100
Flow Sheet Cont. Care BP Eye Exam Foot Exam HbA1c Lipid Profile Flu Vaccine Pneu.Vaccine
Mono Exam
0
10
20
30
40
50
60
70
80
90
100
Flow Sheet Cont. Care BP Eye Exam Foot Exam HbA1c Lipid Profile Flu Vaccine Pneu.Vaccine
Mono Exam
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2004CCNCCCNC
Community Care of North Carolina
Diabetes 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%
A c c e
s s I I C a r
e W N C
A c c e s s C
a r e
C a r o l i n
a C H P
C C C C
C e n t r
a l P i e
d m o n
t C H
P
E a s t e
r n C a r o
l i n a
G r e a
t e r M e c k
l e n b u
r g
L o w e
r C a p e
F e a
r
N o r t h
e r n P i e d
m o n t
P 4 H M
S a n d
h i l l s
S o u t h
e r n P i e
d m o n
t
W a k
e
HbA1c Range
% o f P a t i e n t s
w i t h i n e a c h H b A 1 c R a n g e
< 7.0 7.0 - 8.0 8.0 - 9.0 9.0 - 10.0 > 10.0
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2004CCNCCCNC
Gat her ing and Shar ing t heResul tsGat her ing and Shar ing t heResul ts Utilizing claims data
Chart Audits (contract with NC AHEC)
Practice profiles
Utilizing claims data
Chart Audits (contract with NC AHEC)
Practice profiles
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2004CCNCCCNC
Example Practice Profile
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2004CCNCCCNC
Cost /Benef i t Est im at esCost /Benef i t Est im at es
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2004CCNCCCNC
Com m uni t y Care o f Nor t h Caro l inaCom m uni t y Care o f Nor t h Caro l ina
Cost - $8.1 Million
(Cost of Community Care operation)
Savings - $60,182,128 compared to FY02 Savings- $203,423,814 compared to FFS
(Mercer Cost Effectiveness Analysis – AFDC only for
Inpatient, Outpatient, ED, Physician Services, Pharmacy,Administrative Costs, Other)
Cost - $8.1 Million
(Cost of Community Care operation)
Savings - $60,182,128 compared to FY02
Savings- $203,423,814 compared to FFS
(Mercer Cost Effectiveness Analysis – AFDC only for
Inpatient, Outpatient, ED, Physician Services, Pharmacy,Administrative Costs, Other)
J u ly 1, 2002 – J un 30, 2003J u ly 1, 2002 – J un 30, 2003
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2004CCNCCCNC
Cost Savings for SFY 2004J u ly 1 , 2003- J une 30, 2004
Cost Savings for SFY 2004J u ly 1 , 2003- J une 30, 2004
Cost - $10.2 million
(cost of CCNC operations)
Savings- $124 million compared to SFY 03
Savings $225 million compared to FFS
Cost - $10.2 million
(cost of CCNC operations)
Savings- $124 million compared to SFY 03
Savings $225 million compared to FFS
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2004CCNCCCNC
Want t o K now More?Want t o K now More?
www.communitycarenc.comwww.communitycarenc.com
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2004CCNCCCNC
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