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

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Improving Medicaid Quality and Controlling Costs
by Building Community Systems of Care The Case
for Medical Homes and Community Networks NCs
Approach to Healthcare
L Allen Dobson Jr MD FAAFP Vice President
Carolinas Healthcare System Former Assistant
Secretary Medicaid Director NC Dept Health and
Human Services
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Improving Quality and Controlling Medicaid
CostsDeveloping Community Care of North
CarolinaWhy It Was Needed?
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First - Background

• NC is mainly a rural state not well suited for
  traditional commercial managed care
• NC is dominated by small practices and loosely
  organized medical systems
• The county system remains very strong
• Since early 1990s, NC has had in place across
  the state, Carolina Access, a medical home
  program for Medicaid recipients

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Primary Goals

• Improve the care of the Medicaid population while
  controlling costs
• Develop Community Networks capable of managing
  recipient care
• Develop the systems needed to improve chronic
  illness
• Fully develop the Medical Home

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Key Visions

• Managed not regulated
• CCNC is a clinical program not a financing
  mechanism
• Public-private partnership
• The medical home is key for success
• Community-based, physician led
• Quality and system oriented
• Economizing through raising quality rather than
  lowering fees

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Basic Operating Premise

• Regardless of who manages Medicaid, North
  Carolinas physicians, hospitals, health
  departments, and other safety net providers will
  be serving the patients
• Ownership of the improvement process must be
  vested in those who have to make it work
• Providers who care for patients must work
  together
• The State should partner with and support our
  community providers who are willing to build the
  care systems that are needed
• Focus on quality improvement
• Information and feedback are key
• System changes can be applied to other
  populations of patients

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Community Care of North Carolina

• Joins other community providers (hospitals,
  health departments and departments of social
  services) with primary care physicians
• Designated primary care medical home
• Creates community networks that assume
  responsibility for managing recipient care

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THEN
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Community Care of North Carolina Now in 2008

• Focuses on improved quality, utilization and cost
  effectiveness of chronic illness care
• 14 Networks with more than 3500 Primary Care
  Physicians (1200 medical homes)
• Over 785,000 Medicaid enrollees
• Now mandated inclusion of Aged, Blind and
  Disabled
• and SCHIP by General Assembly

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Community Care Networks

• Non-profit organizations
• Includes all providers including safety net
  providers
• Medical management committee
• Receive 3.00 pm/pm from the State
• Hire care managers/medical management staff to
  work with PCPs
• PCP also get 2.50 pmpm to serve as medical home
  and to participate in Disease Management and
  Quality Improvement
• NC Medicaid pays 95 of Medicare FFS

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Each Network Now Has

• Part-time paid Medical Director role is
  oversight of quality efforts, meets with
  practices and serves on Sate Clinical Directors
  Committee
• Clinical Coordinator oversees the overall
  network operations
• Care Managers small practices share/large
  practices may have their own assigned
• Now all networks have a PharmD to assist with
  medication management of high cost patients

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Key Innovations

• Provider networks organized by local providers
  and are physician led
• Evidenced based guidelines are adopted by
  consensus rather than dictated by the state
• Medical Homes are given the resources for care
  coordination and get timely feedback on results
• Inclusion of other safety net providers and human
  service agencies
• We are about building local systems of
  care rather
• than changing how we pay for services

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Current State-wide Disease and Care Management
Initiatives

• Asthma
• Diabetes
• Pharmacy Management (PAL, Nursing Home
  Polypharmacy)
• Dental Screening and Fluoride Varnish
• Emergency Department Utilization Management
• Case Management of High Cost-High Risk
• Congestive Heart Failure (CHF) (2006)
• Rapid Cycle Quality Improvement

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Network Specific Quality Improvement Initiatives

• Assuring Better Child Development (ABCD)
• ADD/ADHD
• NC HealthNet-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

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New Network Pilots

• Aged, Blind and Disabled (ABD)
• Depression Screening and Treatment
• Mental Health Integration
• Mental Health Provider Co-Location
• E-Rx
• Partner with AHEC to support Improving
  Performance in Practice Initiative
• Medical Group Visits
• Dually Eligible Recipients

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Results
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Key Quality 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 steroid
• Diabetes
• 15 increase in quality measures

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Cost/Benefit Estimates
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Community Care of North CarolinaCost Savings

• Cost - 10.2 Million yearly
• (Cost of Community Care Operations)
• Savings - 60 million SFY03
• Savings - 124 million SFY04
• Savings- 81 million SFY05
• Savings- 161 million SFY06
• NC Medicaid Administrative costs only 6!
• (Mercer Cost Effectiveness Analysis AFDC only
  for Inpatient, Outpatient, ED, Physician
  Services, Pharmacy, Administrative Costs, Other)

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Community Care of North Carolina in the
news

• October 3, 2007 Community Care of North
  Carolina wins the 2007 Annie E. Casey Innovations
  in American Government Award given by the Kennedy
  School of Government at Harvard University

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Next Steps

• Strengthen the ability of the medical home to
  manage chronic illness care
• Enhance the ability of practices/networks to
  support patient self-management
• Integrate specialist expertise into care
  improvement process
• Investing in improved Clinical Information System
• Expansion of CCNC to other populations ( Medicare
  and the uninsured)

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Growing Numbers of Uninsured in NC

• More than 1.5 million non-elderly people in North
  Carolina (20) were uninsured (2006)
• Approximately three-fifths of the uninsured have
  low incomes (lt200 of the federal poverty
  guidelines), and more than half have someone in
  the household working for a small employer
• Between 2000-2006, North Carolina experienced a
  larger increase in the numbers of uninsured, and
  larger decrease in employer-based coverage than
  most of the country

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Low Income Adults Most Likely to be Uninsured

• Low income adults have the highest likelihood of
  being uninsured
• 680,000 uninsured are low income adults (lt200
  FPG)
• Medicaid is a publicly-funded entitlement program
  that provides health insurance to some low-income
  individuals and families
• Medicaid does not cover all low-income families
• Single, childless adults who are not disabled or
  elderly cannot qualify, regardless of how poor

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NC Health Care Safety Net

• North Carolina has a wide array of health
  caresafety-net organizations with a mission to
  serve the uninsured on a free or reduced-cost
  basis
• Examples include
• Community and migrant health centers
• Free clinics
• State-funded rural health clinics
• Health departments
• Hospitals
• AHEC residency clinics
• Other non-profit organizations

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Safety Net Not Sufficient to Meet Needs of
Uninsured

• Health care safety-net organizations are not
  available in every community
• NC IOM study (2005) showed that only 25 of
  uninsured receive primary care through safety-net
  organizations- the rest is provided by private
  primary care or hospitals
• Even when primary care safety-net capacity
  exists, services are not adequate to meet all of
  the health care needs of the uninsured
• Lack access to specialty services, drugs,
  behavioral health, dental care
• Existing safety-net resources not well integrated

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Improving the Health Care Safety Net

• Health care professionals and institutions have
  taken a leadership role in expanding the safety
  net
• NCGA and foundations provide critical funding
• Primary care Project Access, Free Clinics, CCNC
• Medication assistance NC Rx
• Community integration efforts Health Net
• Local foundations have also helped fund a new
  program CareShare

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Take Home Thoughts
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Key Points

• Key attributes of CCNC are replicable in other
  states despite the idiosyncrasies of NC
• Key principles may have role in non government
  programs
• Many states have rural areas and undeveloped
  markets that may benefit from local system
  development
• Operations vary by community CCNC principles
  allow local variability
• Controlling cost a must for sustainability in any
  expansion to the uninsured

The medical home and community system
development are the keys to success!
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Want to Know More?

• www.communitycarenc.com