Transcript Document
Community Care of North Carolina
2012 Overview
Medicaid challenges
Lowering reimbursement reduces access and
increases ER usage/costs
Reducing eligibility or benefits limited by federal
“maintenance of effort”; raises burden of
uninsured on community and providers
The highest cost patients are also the hardest to
manage (disabled, mentally ill, etc.) ─ CCNC has
proven ability to address this challenge
Utilization control and clinical management only
successful strategy to reining in costs overall
Community Care
Provides NC with:
Statewide medical home and care management
system in place to address quality, utilization and
cost
100 percent of all Medicaid savings remain in state
A private sector Medicaid management solution
that improves access and quality of care
Medicaid savings that are achieved in partnership
with – rather than in opposition to – doctors,
hospitals and other providers.
Key Tenets of
Community Care
Public-private partnership
“Managed not regulated”
CCNC is a clinical partnership, not just a financing
mechanism
Community-based, physician-led medical homes
Cut costs primarily by greater quality, efficiency
Providers who are expected to improve care must
have ownership of the improvement process
Primary Goals of
Community Care
Improve the care of Medicaid population while
controlling costs
A “medical home” for patients, emphasizing
primary care
Community networks capable of managing
recipient care
Local systems that improve management of
chronic illness in both rural and urban settings
Community Care:
“How it works”
Primary care medical home available to 1.1 million
individuals in all 100 counties.
Provides 4,500 local primary care physicians with
resources to better manage Medicaid population
Links local community providers (health systems,
hospitals, health departments and other community
providers) to primary care physicians
Every network provides local care managers (600),
pharmacists (26), psychiatrists (14) and medical
directors (20) to improve local health care delivery
Community Care:
“How it works”
The state identifies priorities and provides
financial support through an enhanced PMPM
payment to community networks
Networks pilot potential solutions and monitor
implementation (physician led)
Networks voluntarily share best practice solutions
and best practices are spread to other networks
The state provides the networks access to data
Cost savings/ effectiveness are evaluated by the
state and third-party consultants (Mercer, Treo
Solutions).
Community Care Networks
Alleghany
Ashe
Stokes
Granville
Caldwell Alexander
Rutherford
Graham
Jackson
Clay
Macon
Cleveland
Gaston
Nash
Tyrrell
Edgecombe
Washington
Randolph
Wilson
Chatham
Rowan
Pitt
Cabarrus
Stanly
Mecklenburg
Union
Johnston
Lee
Harnett
Montgomery
Wayne
Moore
Richmond
Anson
Lenoir
Hoke
Cumberland
Craven
Pamlico
Sampson
Jones
Duplin
Onslow
Robeson
Bladen
Pender
Hanover
Columbus
Brunswick
Source: CCNC 2012
Beaufort
Greene
Scotland
AccessCare Network Sites
AccessCare Network Counties
Community Care of Western North Carolina
Community Care of the Lower Cape Fear
Carolina Collaborative Community Care
Community Care of Wake and Johnston Counties
Community Care Partners of Greater Mecklenburg
Carolina Community Health Partnership
Dare
Martin
Lincoln
Henderson
Polk
Cherokee
Catawba
Durham
Davidson
Burke
McDowell
Bertie
Franklin
Orange
Wake
Iredell
Buncombe
Guilford
Davie
Madison
Haywood
Alamance
Yadkin
Forsyth
Swain
Hertford
Halifax
Wilkes
r
Gates
a
Rockingham Caswell Person
Chowan
Watauga
Northhampton
Warren
Surry
Community Care Plan of Eastern Carolina
Community Health Partners
Northern Piedmont Community Care
Northwest Community Care
Partnership for Health Management
Community Care of the Sandhills
Community Care of Southern Piedmont
Hyde
Community Care Networks
Are non-profit organizations that receive a per-member,
per-month (PMPM) payment from the state
Primary care providers also receive a PMPM payment
Provides resources needed to manage enrolled
population, reducing costs
Central office of CCNC is also a nonprofit 501(c)(3)
Seek to incorporate all providers, including safety net
providers
Have Medical Management Committee oversight
Hire care management staff
Each network has:
Clinical Director
A physician who is well known in the community
Works with network physicians to build compliance with
care improvement objectives
Provides oversight for quality improvement in practices
Serves on the State Clinical Directors Committee
Network Director who manages daily operations
Care Managers to help coordinate services for
enrollees/practices
PharmD to assist with Med management of high cost
patients
Psychiatrist to assist in mental health integration
Current State-wide Disease
and Care Management Initiatives
Asthma (1998 – 1st Initiative)
Diabetes (began in 2000)
Dental Screening and Fluoride Varnish (piloted for the state in 2000)
Pharmacy Management
Prescription Advantage List (PAL) - 2003
Nursing Home Poly-pharmacy (piloted for the state 2002 - 2003)
Pharmacy Home (2007)
E-prescribing (2008)
Medication Reconciliation (July 2009)
Emergency Department Utilization Management (began with Pediatrics 2004 / Adults 2006 )
Case Management of High Cost-High Risk (2004 in concert with rollout of initiatives)
Congestive Heart Failure (pilot 2005; roll-out 2007)
Chronic Care Program – including Aged, Blind and Disabled
Pilot in 9 networks 2005 – 2007
Began statewide implementation 2008 - 2009
Behavioral Health Integration (began fall 2010)
Palliative Care (began fall 2010)
Chronic Care Process
Chronic Care Program
Components
Enrollment/Outreach
Screening/Assessment/Care Plan
Risk Stratification/ Identify Target Population
Patient Centered Medical Home
Transitional Support
Pharmacy Home – Medication Reconciliation,
Polypharmacy & Polyprescribing
Care Management
Mental Health Integration
Informatics Center
Self Management of Chronic Disease
Community Care’s
Informatics Center
Informatics Center ─ Medicaid claims data
Utilization (ED, Hospitalizations)
Providers (Primary Care, Mental Health, Specialists)
Diagnoses – Medications – Labs
Costs
Individual and Population Level Care Alerts
Real-time data
Hospitalizations, ED visits, provider referrals
Community Care’s
Informatics Center
Care Management Information System (CMIS)
Pharmacy Home
Quality Measurement and Feedback Chart Review
System
Informatics Center Reports on prevalence, highopportunity patients, ED use, performance
indicators
Provider Portal
Provider portal in action
“Quality first” approach
leads to savings
Recent analysis by Milliman, Inc. estimated savings
achieved by CCNC from 2007 through 2010
Employed multiple methodologies to answer the
question: “What would costs have been without
CCNC?”
Included data on children, adults, Aged Blind &
Disabled
Risk adjusted to review results across similar patient
cohorts
17
“Quality first” approach also
leads to savings
Milliman’s estimate: nearly a billion dollars over a
period of 4 years
State Fiscal Year
Total Annual Savings
2007
$103,000,000
2008
$204,000,000
2009
$295,000,000
2010
$382,000,000
$984,000,000
18
Cost savings estimate:
Treo Solutions
Using the unenrolled fee-for-service population, risk adjustments were made by creating a total cost of
care (PMPM) set of weights by Clinical Risk Group (CRG), with age and gender adjustments. This
weight set was then applied to the entire NC Medicaid Population. Using the FFS weight set and base
PMPM, expected costs were calculated. This FFS expected amount was compared to the actual
Medicaid spend for 2007, 2008, 2009. The difference between actual and expected spend was
considered savings attributable to CCNC. Treo Solutions, Inc., June 2011.
Cost savings estimate:
Mercer, Inc.
Earlier studies by Mercer, Inc. estimated CCNC savings as:
State Fiscal Year
Estimated Savings
2005
$77 - $81M
2006
$154 - $170M
2007
$135 - $149M
2008
$156 - $164M
2009
$186 - $194M
Variance from Expected
Spending
Adjusting for the severity of illness of the population, total spending for CCNC enrollees
has been lower than expected each of the past 3 years.
4.0%
2.5%
2.0%
0.0%
2007
2008
2009
-2.0%
-4.0%
-3.5%
-6.0%
-5.4%
-5.9%
-6.9%
-8.0%
-8.7%
-10.0%
-10.6%
-12.0%
Child
Adult
Total
-6.6%
-7.4%
Quality results
Community Care is in the top 10 percent in US in HEDIS for
diabetes, asthma, heart disease compared to commercial
managed care.
More than $700 million in state Medicaid savings since
2006.
Adjusting for severity, costs are 7% lower than expected.
Costs for non-Community Care patients are higher than
expected by 15 percent in 2008 and 16 percent in 2009.
For the first three months of FY 2011, per member per
month costs are running 6 percent below FY 2009 figures.
For FY 2011, Medicaid expenditures are running below
forecast and below prior year (over $500 million).
Quality HEDIS Measures
Cholesterol Control LDL <100
Diabetes
Cholesterol Testing
Blood Pressure Control <130/80
CCNC 2009
A1C Control <9.0
CCNC 2010
National Medicaid HMO HEDIS mean
Cardiovascular
Disease
A1C Testing
Cholesterol Control LDL<100
Blood Pressure Control <140/90
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Community Care Advantage
Flexible structure that invests in the community
(rural and urban) -- provides local jobs
Fully implemented in all 100 counties
All the savings are retained by the State of North
Carolina
Very low administrative costs
Ability to manage the entire Medicaid population
(even the most difficult)
Proven, measurable results
Team effort by NC providers that has broad
support
Building on Success
Other payers and major employers are
interested in benefit’s of CCNC’s approach
Medicare 646 demo (22 counties) caring for
Medicare patients
Beacon Community (3 counties), all payers
Multi-payer primary care demo (7 rural counties)
Medicare, Medicaid, Blue Cross and Blue Shield
of North Carolina, State Employees Health Plan
New major employer initiative (40,000 patients)
Next Steps for CCNC
Build out Informatics Center and Provider Portal as
a shared resource for all communities
Add specialists to CCNC
Develop budget and accountability model for NC
Medicaid
Implement additional multi-payer projects
Work with NCHA, IHI on best practices for reducing
readmissions
Facilitate Accountable Care Organizations (ACOs)