Whats Better Than A Medical Home A Statewide Network of Medical Homes

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Whats Better Than A Medical Home?
A Statewide Network of Medical Homes

• The NORTH CAROLINA Experience
• Chuck Willson MD
• Clinical Professor of Pediatrics
• February 13, 2009

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What is a Medical Home?

• Depends whom you ask
• American Academy of Pediatrics
• Other Primary Care Groups
• NCQA
• Specialty Societies
• The real question should be what do we need ( as
  individuals, communities, states)?

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The National Institute of Health 2001Crossing
the Quality Chasm

• Episodic visits
• Professional autonomy
• Professional control
• Information a record
• Decision based on training and experience
• Preventing harm an individual responsibility
• Secrecy necessary
• Reactionary
• Costs concealed
• Professional roles trump system of care

• Care based on continuous healing relationship
• Care customized
• Patient is source of control
• Knowledge and information flows freely
• Decisions are evidence-based
• Safety is systematized
• Transparency is necessary
• Needs anticipated
• Waste is identified/decreased
• Cooperation among clinicians is a priority

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Drivers of the New System

• Consumers Medical care is too expensive
  consumers must be purchasers
• Government Medical care must provide better
  value (cost data) and be transparent (physician
  performance data)
• Payers Demand value for dollars expended
• Demographics 50 increase in patients over 85yrs
  old by 2020.

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Whos not HAPPY with the Old System?

• Patients
• Docs
• Employers/ Payers
• People who call me everyday to get advice on what
  doc to see or how to get an appointment
• Are you happy with your medical home?

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Our Assumptions

• Better access to an enhanced primary care medical
  home will improve outcomes
• Higher quality care will lead to improved
  outcomes
• Better access and higher quality will bring cost
  savings
• Better reimbursement will bring a better network
• Healthcare is based on local resources
• Data will drive the system

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The Essentials of CCNC

• Networks of Primary Care Offices
• Governmental Partnership
• Community Partnerships
• Physician Champions
• Resources to manage patients
• Adequate reimbursement

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Our structure

• Partnership with state DHHS, ORHCC
• Fiscal entities at network level 501C3
• Statewide Clinical Directors
• Local care management committees
• North Carolina Community Care Networks Inc. 501C3

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How We Started in 19979 pilot sites across the
state

• Two county-wide pilots Pitt and Cabarus
• One HMO county Mecklinburg (Charlotte)
• One professional society-based pilot (NCPS)
• Several health department-based projects
• 2000 County-wide model accepted
• 2006 no more HMOs in Charlotte

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Community Care of North Carolina
CCNC Networks as of October 2007
AccessCare Network Sites
AccessCare Network Counties
Access II Care of Western NC
Access III of Lower Cape Fear
Community Care of Wake and Johnston Counties
Central Care Health Network
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Community Care of North Carolina networks of
medical homes

• Fiscal entity (3pmpm)
• Practice (2.50pmpm)
• Evidence-based disease management
• Case managers (one per 3300 patients)
• Practice profiles
• Practices must have availability 24/7/365
• Hospital privileges
• Specialist as pcp in complex patients

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The Enhanced Medical Home

• Patient-centered
• Physician-guided
• Cost-effective
• Longitudinal care that encompasses and values the
  art and science of medicine
• Evidence-based and data-driven
• Are our practices all medical homes? (depends
  whom you ask AAP, ACP, NCQA)

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What Have We Accomplished?

• Cost-savings Mercer Audits gt200million
• Cost of program about 50 million
• Improved outcomes
• No physician or physician practice has dropped
  out
• Patients permitted to change medical home

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Community Care of NCA Template for Innovation

• Nursing Home Pharmacy Initiative
• OTC meds by prescription
• NC Physician Advisory Group to DMA
• Disease management of CHF, OM, Depression
• Improving Pediatric Access Through Collaborative
  Care (IMPACC)
• Improving Performance in Practice (IPIP)
• The NC Healthcare Quality Alliance (NCHQA)

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Weaknesses of Our Program

• No stick to make patients use PCMH
• Difficult to touch every practice
• For complex patients, 2.50 pmpm isnt enough
• Constant legislative battle to maintain funding
• Savings are not rolled back into program
• Difficult to export vested interests

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Where Are We Going Now in NC?

• Access is assumed for the individual
• Focus more closely on high cost/high complexity
  patients (ABD)
• New populations Medicare 646 waiver, dual
  elgibles
• Focus on transitions

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The Chronic Care Model(Wagner et al)

• Evidence-based, planned care
• Reorganization of practice systems and provider
  roles
• Improved patient self-management support
• Increased access to expertise
• Greater availability of clinical information

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Reimbursement

• The old system IM makes money on labs
• The old system Peds shortens visits, increase
  FFS visits
• New system reimburse physician cognitive
  activity
• New system practice support such as case
  managers, IT, practice consultants
• Transparency of costs and outcomes

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Who Needs An Enhanced Medical Home?

• The patient
• The doctor
• The payer
• You and your family

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Who Needs A Statewide Network of Enhanced Medical
Homes?

• Your state
• Your primary care physicians
• Your specialists
• Your legislators
• Your citizens

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I Welcome Your Questions