Upload
scout
View
16
Download
0
Embed Size (px)
DESCRIPTION
HOME. NEXT. LAST. “ Improving Medicaid Quality and Controlling Costs by Building Community Systems of Care”. L. Allen Dobson ,Jr. MD FAAFP Assistant Secretary NC Department of Health & Human Services. - PowerPoint PPT Presentation
Citation preview
2004CCNCCCNC
“ Improving Medicaid Quality and Controlling Costs by Building Community Systems of Care”
“ Improving Medicaid Quality and Controlling Costs by Building Community Systems of Care”
L. Allen Dobson ,Jr. MD FAAFPAssistant Secretary NC Department of Health &Human Services
L. Allen Dobson ,Jr. MD FAAFPAssistant Secretary NC Department of Health &Human Services
HOME
NEXT
LAST
2004CCNCCCNC
Greetings from Governor Mike Easley, Secretary Carmen Hooker-Odom and your colleagues in NC
Greetings from Governor Mike Easley, Secretary Carmen Hooker-Odom and your colleagues in NC
2004CCNCCCNC
Major Department GoalsMajor Department 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
Current NC Medicaid FactsCurrent NC Medicaid Facts1.6 million unduplicated eligibles covered (15.2% 0f
population)810,000 children covered45% of all babies born covered30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%Physicians account for only 9-10% of costs!!!Over $1.5 billion spend on mental health servicesTotal budget over $ 8.5 billion
1.6 million unduplicated eligibles covered (15.2% 0f population)
810,000 children covered45% of all babies born covered30 % of recipients consume 74.5% resources Inpatient care (hosp,NH,MRC) consumes 40%Physicians account for only 9-10% of costs!!!Over $1.5 billion spend on mental health servicesTotal budget over $ 8.5 billion
2004CCNCCCNC
Improving Quality&
Controlling Medicaid Costs
Improving Quality&
Controlling Medicaid Costs
Developing Community Care of NC
Why It Was Needed?
Developing Community Care of NC
Why It Was Needed?
2004CCNCCCNC
Why We Started CCNC as PilotWhy We Started CCNC as Pilot NC is a mainly rural state not well suited for and with
little managed care Successful Carolina Access program linked
recipients with PCP in all 100 counties PCCM model alone not effective in cost control Little efforts around quality State was piloting Managed Care program in 2 metro
areas- needed alternative
NC is a mainly rural state not well suited for and with little managed care
Successful Carolina Access program linked recipients with PCP in all 100 counties
PCCM model alone not effective in cost control Little efforts around quality State was piloting Managed Care program in 2 metro
areas- needed alternative
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 health services are not coordinated with the medical care system
Duplication of services at the local level State “Silo Funding”
2004CCNCCCNC
Primary GoalsPrimary Goals
Improve the quality of care provided to the Medicaid population while controlling costs
Develop Community based networks capable of managing populations
Fully Develop the Medical Home Model
Improve the quality of care provided to the Medicaid population while controlling costs
Develop Community based networks capable of managing populations
Fully Develop the Medical Home Model
HOME
NEXT
LAST
2004CCNCCCNC
Community Care of North CarolinaCommunity Care of North Carolina
Joins other community providers (hospitals, health departments and departments of social services) with physicians
Designated medical home
Creates community networks that assume responsibility for managing recipient care
Joins other community providers (hospitals, health departments and departments of social services) with physicians
Designated medical home
Creates community networks that assume responsibility for managing recipient care
Build on ACCESS I (PCCM) 1998-99 as pilot program
Build on ACCESS I (PCCM) 1998-99 as pilot program
HOME
NEXT
LAST
2004CCNCCCNC
1999
Community Care of North Carolina (Access II and III Networks)
Then
2004CCNCCCNC
Community Care of North CarolinaNow in 2007Community Care of North CarolinaNow in 2007
Focuses on improved quality, utilization and cost effectiveness of chronic illness care
15 Networks with more than 3500 Primary Care Physicians (1000 medical homes)
over 750,000 enrollees
Focuses on improved quality, utilization and cost effectiveness of chronic illness care
15 Networks with more than 3500 Primary Care Physicians (1000 medical homes)
over 750,000 enrollees
HOME
NEXT
LAST
2004CCNCCCNC
AccessCare Network SitesAccessCare Network CountiesAccess II Care of Western NCAccess III of Lower Cape Fear
Southern Piedmont Community Care Plan
Community Care Plan of Eastern NC
Community Health Partners Northern Piedmont Community Care
Partnership for Health Management
Sandhills Community Care Network
Community Care of Wake and Johnston Counties
CCNC Spread: 15 networks, 3500 MDs, >750,000 patientsCCNC Spread: 15 networks, 3500 MDs, >750,000 patients
CCNC Networks as of November 2006CCNC Networks as of November 2006
Carolina Collaborative Comm. CareCarolina Community Health Partnership
Comm. Care Partners of Gtr. MecklenburgNorthwest Community Care Network
Central Care Health Network
2004CCNCCCNC
Community Care Networks: Community Care Networks: Non-profit organizations Includes all providers including safety net
providers 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 medical
home and to participate in DM
Non-profit organizations Includes all providers including safety net
providers 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 medical
home and to participate in DMHOME
NEXT
LAST
2004CCNCCCNC
Each Network Now Have:Each Network Now Have:
Part- time paid Medical Director- role is oversight of quality efforts, meets with practices and serves on State Clinical Directors Committee
Clinical Coordinator- oversees the overall network operations
Care Managers- small practices share/large practices may have their own assigned
PharmD to assist with medication management of high cost patients
Part- time paid Medical Director- role is oversight of quality efforts, meets with practices and serves on State Clinical Directors Committee
Clinical Coordinator- oversees the overall network operations
Care Managers- small practices share/large practices may have their own assigned
PharmD to assist with medication management of high cost patients
2004CCNCCCNC
What Networks DoWhat Networks Do Assume responsibility for Medicaid recipients
Implement improved care management and disease management systems ( rapid cycle QI)
Identify costly patients and costly services
Develop and implement plans to manage utilization and cost
Create the local systems to improve care & reduce variability
Assume responsibility for Medicaid recipients
Implement improved care management and disease management systems ( rapid cycle QI)
Identify costly patients and costly services
Develop and implement plans to manage utilization and cost
Create the local systems to improve care & reduce variability
HOME
NEXT
LAST
2004CCNCCCNC
Keys to SuccessKeys to Success Medical and administrative committees that provide
direction on care management activities. Dedicated case managers to carry out such population
management activities as risk assessment, case management, and disease management.
Care management processes that apply both new and existing resources, such as health department support services, in meeting the needs of enrollees.
Regular reporting and profiling of target initiatives that allow networks to monitor their progress in achieving target goals.
Medical and administrative committees that provide direction on care management activities.
Dedicated case managers to carry out such population management activities as risk assessment, case management, and disease management.
Care management processes that apply both new and existing resources, such as health department support services, in meeting the needs of enrollees.
Regular reporting and profiling of target initiatives that allow networks to monitor their progress in achieving target goals.
2004CCNCCCNC
Guidelines for Selecting a Quality Improvement Initiative Guidelines for Selecting a Quality Improvement Initiative There are enough Medicaid enrollees with the disease to obtain
a "return on investment." Evidence exists that best practices lead to predictable and
improved 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 and improved 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 State-wide Disease and Care Management Initiatives
Current State-wide Disease and Care Management Initiatives
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
NEXT
LASTRapid Cycle Quality ImprovementRapid Cycle Quality Improvement
2004CCNCCCNC
Network Specific Quality Improvement InitiativesNetwork Specific Quality Improvement Initiatives
“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, open
access & 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, open
access & diabetes self management) Diabetes Disparities Medical Home/ED Communications
2004CCNCCCNC
New Network PilotsNew Network Pilots
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
Asthma and Diabetes InitiativesAsthma began 1998 Diabetes began 2000
Asthma and Diabetes InitiativesAsthma began 1998 Diabetes began 2000
Adopted nationally accepted best practice guidelines
Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level
Adopted nationally accepted best practice guidelines
Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level
2004CCNCCCNC
Diabetes MeasuresDiabetes 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 12 months 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 first dose 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 12 months 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 first dose was given > 5 yrs ago)
2004CCNCCCNC
Key ResultsKey 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 steroidDiabetes 15% increase in quality measures
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 steroidDiabetes 15% increase in quality measures
2004CCNCCCNC
Gathering and Sharing the ResultsGathering and Sharing the Results
Utilizing claims data Chart Audits (contract with NC AHEC) Practice profiles
Utilizing claims data Chart Audits (contract with NC AHEC) Practice profiles
2004CCNCCCNC
Community Care of North CarolinaDiabetes 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%
HbA1c Range
% o
f P
ati
en
ts w
ith
in e
ach
Hb
A1c R
an
ge
< 7.0 7.0 - 8.0 8.0 - 9.0 9.0 - 10.0 > 10.0
2004CCNCCCNC
Cost/Benefit EstimatesCost/Benefit Estimates
2004CCNCCCNC
Cost Savings for SFY 2004July 1, 2003- June 30, 2004
Cost Savings for SFY 2004July 1, 2003- June 30, 2004
Cost - $10.2 million
(cost of CCNC operations)
Savings- $124 million compared to SFY 03 Savings $225 million compared to FFS
SFY 2005 and 2006 final results pending but similar results
Cost - $10.2 million
(cost of CCNC operations)
Savings- $124 million compared to SFY 03 Savings $225 million compared to FFS
SFY 2005 and 2006 final results pending but similar results
2004CCNCCCNC
Cabarrus County- 4 Year ResultsCabarrus County- 4 Year Results
4 5 0
5 0 0
5 5 0
6 0 0
S F Y 0 1 S F Y 0 2 S F Y 0 3 S F Y 0 4 S F Y 0 5
C a b a r r u s
R o w a n
# R E F !
S t a t e w id e T o t a l
% Change
SF02 SF03 SF04 SF05 4 yr
-1% -7% 2.90% 1.67% -3%
6% 0% 4.30% 7.00% 17%
5% 0% 5.30% 7.00% 17%
Cabarrus
Rowan
State
2004CCNCCCNC
Our Plan for Further System Change
Our Plan for Further System Change
Governor’s Quality Initiative ( BCBC, SEHP, Medicaid & Medicare and other major insurers)- over 85% of NC insured included
NC Health Net (coordinated free care) Mental Health Transformation/Integration Medicare 646 Redesign Waiver
Governor’s Quality Initiative ( BCBC, SEHP, Medicaid & Medicare and other major insurers)- over 85% of NC insured included
NC Health Net (coordinated free care) Mental Health Transformation/Integration Medicare 646 Redesign Waiver
2004CCNCCCNC
Want to Know More?Want to Know More?
www.communitycarenc.comwww.communitycarenc.com
2004CCNCCCNC
HOME