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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



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



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



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



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”



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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)



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



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



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



2004CCNCCCNC

Example Practice Profile



2004CCNCCCNC

Cost /Benef i t Est im at esCost /Benef i t Est im at es



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



2004CCNCCCNC

Want t o K now More?Want t o K now More?

www.communitycarenc.comwww.communitycarenc.com

http://www.communitycarenc.com/






2004CCNCCCNC

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