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Community Care of North Carolina


Community Care of North Carolina 2012 Overview * * * * * * * * * * * * * * * * * * * * * * Medicaid challenges Lowering reimbursement reduces access and increases ER ... – PowerPoint PPT presentation

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Title: Community Care of North Carolina

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
  • 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 ofCommunity 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,
  • 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
  • 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

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
  • The state provides the networks access to data
  • Cost savings/ effectiveness are evaluated by the
    state and third-party consultants (Mercer, Treo

Community Care Networks
AccessCare Network Sites Community Care Plan
of Eastern Carolina AccessCare Network
Counties Community Health Partners Community
Care of Western North Carolina Northern
Piedmont Community Care Community Care of the
Lower Cape Fear Northwest Community
Care Carolina Collaborative Community
Care Partnership for Health Management Community
Care of Wake and Johnston Counties Community
Care of the Sandhills Community Care Partners of
Greater Mecklenburg Community Care of Southern
Piedmont Carolina Community Health
Source CCNC 2012
Community Care Networks
  • Are non-profit organizations that receive a
    per-member, per-month (PMPM) payment from the
  • Primary care providers also receive a PMPM
  • Provides resources needed to manage enrolled
    population, reducing costs
  • Central office of CCNC is also a nonprofit
  • 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
  • Serves on the State Clinical Directors Committee
  • Network Director who manages daily operations
  • Care Managers to help coordinate services for
  • PharmD to assist with Med management of high cost
  • Psychiatrist to assist in mental health

Current State-wide Diseaseand Care Management
  • 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
  • Chronic Care Program including Aged, Blind and
  • 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 Cares Informatics Center
  • Informatics Center - Medicaid claims data
  • Utilization (ED, Hospitalizations)
  • Providers (Primary Care, Mental Health,
  • Diagnoses Medications Labs
  • Costs
  • Individual and Population Level Care Alerts
  • Real-time data
  • Hospitalizations, ED visits, provider referrals

Community Cares Informatics Center
  • Care Management Information System (CMIS)
  • Pharmacy Home
  • Quality Measurement and Feedback Chart Review
  • Informatics Center Reports on prevalence,
    high-opportunity patients, ED use, performance
  • 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
  • Included data on children, adults, Aged Blind
  • Risk adjusted to review results across similar
    patient cohorts

Quality first approach also leads to savings
Millimans estimate nearly a billion dollars
over a period of 4 years
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
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

Quality HEDIS Measures
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 benefits of CCNCs 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
  • Implement additional multi-payer projects
  • Work with NCHA, IHI on best practices for
    reducing readmissions
  • Facilitate Accountable Care Organizations (ACOs)