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NORTH CAROLINA OBSTETRICAL AND GYNECOLOGICAL SOCIETY &
THE NORTH CAROLINA SECTION OF ACOG
Friday, April 8 Presentations
This activity is jointly provided by the American College of Obstetricians and Gynecologists.
3/21/2016
1
Making healthcare remarkable
Stay Ahead:Avoiding the Complications of Obstetrical Hemorrhage
John R. Allbert, MD
Maternal Fetal Medicine Associates
Obstetrical HemorrhageGoals and Objectives
Be able to identify high risk patients obstetrical hemorrhage
Know how to assess the severity of the hemorrhage
Understand the key components of a hemorrhage protocol
Case Presentation
18 y/o G-1 P-0 at 22 weeks
IUFD with complete abruption
Large intrauterine hematoma
BP 82/20, P-128
Urine output <10cc past 4 hours
Cervix long, thick and closed
Severe Obstetrical HemorrhageEBL > 1000 ml
Postpartum hemorrhage 1-5% of deliveries, 15% will be severe
Risk of death 1/100,000 in developed countries and 1/1000 in undeveloped countries
Most common reason postpartum patients are admitted to the ICU
Hemorrhagic shock can lead to Sheehan’s Syndrome, occult myocardial ischemia or death
Maternal Mortality and Severe Morbidity
Cause Mortality(1-2 per 10,000)
ICU Admit(1-2 per 1000)
Severe Morbidity(1-2 per 100)
VTE and AFE 15% 5% 2%
Infection 10% 5% 5%
Hemorrhage 15% 30% 45%
Preeclampsia 15% 30% 30%
Cardiac Disease 25% 20% 10%
North Carolina: Mortality Mostly Preventable
Cause of Death (n=108) % of All Deaths % Preventable
Cardiomyopathy 21% 22%
Hemorrhage 14 93PIH 10 60
CVA 9 60
Chronic condition 9 89
AFE 7 0
Infection 7 43
Pulmonary embolism 6 17
Berg CJ, Harper MA, Obstet Gynecol. 2005;106:1228
3/21/2016
2
POSTPARTUM HEMORRHAGEPlacenta Percreta
12 Week Uteroisthmic Pregnancy
12 Week Uteroisthmic Pregnancy MRI Hepatic Rupture
Abruption
PIH/HELLP
Amniotic fluid embolus
Acute fatty liver
Accreta
Uterine scar pregnancy
PregnancyLife Threatening Hemorrhage
Uterine infection
Uterine rupture
Hydatiform mole
Retained IUFD
Uterine inversion
Lacerations
Council on Patient Safety in Women’s Healthcare
Partnership for Maternal Safety3 Maternal Safety Bundles in July 2013
Postpartum Hemorrhage
Severe Hypertension in Pregnancy
Venous Thromboembolism Prevention
3/21/2016
3
So What is a Bundle? So what’s a bundle?
Not a guideline
Selection of existing guidelines and recommendations in a form that aids implementation and consistency of practice
All elements necessary AND sufficient
All or nothing measurement, you either did it or you didn’t
Main EK, Obstet Gynecol 2015;126:155
Bundle Examples
Central Lines
using proper hygiene and sterile contact barriers; properly cleaning the patient’s skin; finding the best vein possible for the IV; checking every day for infection; and removing or changing the line only when needed.
Ventilator-associated Pneumonia
raising the head of the patient’s bed between 30 and 40 degrees; giving the patient medication to prevent stomach ulcers; preventing blood clots when patients are inactive; and seeing if patients can breathe on their own without a ventilator
Involvement Was Diverse
American Association of Blood Banks
American Academy of Family Physicians
American College of Nurse-Midwives
ACOG
AWHONN
SMFM
Society of Obstetric Anesthesia and Perinatology
Obstetric Hemorrhage BundleEndorsed by the Council July 2014
Improve Readiness to hemorrhage by identifying standardized protocols (general and massive)
Improve Recognition of OB hemorrhage by performing on-going objective quantification of actual blood loss
Improve Response to hemorrhage by utilizing unit-standard, stage-based, hemorrhage emergency management plans with checklists
Improve Reporting/Systems Learning of OB hemorrhage by performing regular on-site multi-professional hemorrhage drills
Obstetric Hemorrhage BundleFour Action Domains
Readiness
Recognition and Prevention
Response
Reporting/Systems Learning
3/21/2016
4
Readiness
Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compression stitches
Immediate access to hemorrhage medications
Establish a response team: who to call when help is needed, (blood bank, anesthesia, pharmacy, advance gynecologic surgery, social services, chaplain)
Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)
Unit education on protocols, unit-based drill debriefs
Hemorrhage MedicationsStorage
Obstetric HemorrhageMedication Kit
[ ] Oxytocin (Pitocin) 20 units/liter 1 bag [ ] Oxytocin (Pitocin) 10 units 2 vials [ ] 15-methyl PGF2α (Hemabate) 250 micrograms/milliliters 1 ampule * [ ] Misoprostol (Cytotec) 200 microgram tablets 5 tabs [ ] Methylergonovine (Methergine) 0.2 milligrams/milliliters 1 ampule * * Needs Refrigeration
Postpartum Hemorrhage Kit
Obstetric HemorrhageHemorrhage Cart
Vaginal[ ] Vaginal retractors; long weighted speculum
[ ] Long instruments (needle holder, scissors, Kelly clamps, sponge forceps)
[ ] Intrauterine balloon
[ ] Banjo curette
[ ] Bright task light
[ ] Procedural instructions
Cesarean/Laparotomy
[ ] Hysterectomy tray
[ ] #1 chromic or plain catgut suture & reloadable straight needle for B-Lynch sutures
[ ] Intrauterine balloon
[ ] Procedural instructions (balloon, B-Lynch, arterial ligations)
Postpartum Hemorrhage Kit
3/21/2016
5
4 Domains of Patient Safety Bundles
Readiness
Recognition and Prevention
Response
Reporting/Systems Learning
Obstetric HemorrhageRecognition/PreventionEvery Patient
Assessment of hemorrhage risk
Measurement of cumulative blood loss
Universal active management of 3rd stage of labor
Assessment of Hemorrhage RiskPrevention
Helps improve readiness
Early recognition
Increase use of preventive measures
Prepare for early aggressive response to bleeding
Assessment of Hemorrhage Risk
Identifies 25% of patients as high risk
Identifies 60% of patients with severe hemorrhages
Thus 40% of hemorrhages occur in low risk patients
Dilla AJ, Obstet Gynecol 2013;122:120
Admission Risk Assessment & Testing
Low Medium(Type and Screen)
High(Type & Crossmatch)
No known bleeding disorder
Prior C/S or uterine surgery Placenta previa, low lying placenta
≤ 4 previous vaginal births Multiple gestation Suspected accreta
>4 previous vaginal births Hct <30 AND other risk factors
Chorioamnionitis Platelets <70,000-100,000
Previous PPH Known coagulopathy
Large uterine fibroids Active bleeding
Assessment of Hemorrhage RiskPrevention: Assess Risk
Antepartum
Admission to LDR
During labor
Transfer to postpartum care
3/21/2016
6
Obstetric HemorrhagePlacenta Accreta Management
For one or more prior C/S, placenta location must be documented prior to scheduling delivery
Patients at high risk of accreta should:
-Obtain proper imaging
-Be transferred to appropriate level of
care for delivery if accreta is suspected
PLACENTA PERCRETAUltrasound Diagnosis
Accreta at 11 weeks Accreta
Hemorrhage Risk AssessmentPrevention
May indicate need for T&S or T&C
Confirm availability of blood replacement products
Assess need to transfer or confirm availability of surgical or radiologic expertise
Create multidisciplinary plan for women who refuse blood products
4 Domains of Patient Safety Bundles
Readiness
Recognition and Prevention
Response
Reporting/Systems Learning
3/21/2016
7
Obstetric HemorrhageAssessing the Degree of Hemorrhage
Volume of blood already lost (estimated blood loss) Rate of bleeding (at the time of evaluation) Consequences of blood loss: Hemodynamic abnormalities (blood pressure, pulse, urinary output) Hemoglobin/Hematocrit abnormalities Metabolic abnormalities (pH, base deficit, lactic acid) Coagulation abnormalities (PT, PTT, INR, fibrinogen, platelets) Patient’s clinical status (anxious, confused, lethargic)
Postpartum HemorrhageQuantitative Blood Loss QBL
• Perform for every birth and begin immediately after infant delivery and continue until bleeding is stable, (2-4 hrs)
• Visual estimation can underestimate by 33-50%
• QBL reduces the likelihood that clinicians will underestimate the EBL and delay treatment
• “She’s bleeding a lot” vs. “She has a 1200 ml QBL”
Patel,A International J of Gynecol Obstets 2006;93:230
Postpartum HemorrhageQBL• Weight: Total weight of
blood saturated items (laps, chux, cloth pads) –their dry weight. One gram = One milliliter
Direct Measurements: graduated suction canisters, Under-buttocks and OR drapes with calibrated pouches
Postpartum HemorrhagePreventionActive Management of the 3rd Stage of Labor
• Oxytocin 10 unit bolus
• Controlled cord traction, (Brandt maneuver)
• Uterine massage after delivery of the placenta
4 Domains of Patient Safety Bundles
Readiness
Recognition and Prevention
Response
Reporting/Systems Learning
Hemorrhage: How Much is too Much
500 mL for vaginal and >750 mL for C/S
WHO: EBL >500 mL an “alert line” and >1000 mL an “action line”
ACOG (reVITALize): EBL >1000 mL for either vaginal or C/S with enhanced surveillance and early interventions, as needed, for 500-1000 mL
4-5% of women >1000 mL- A clinically significant amount
3/21/2016
8
Determine the Exact Etiology: The 4Ts
Tone: 70%, Atonic uterus
Trauma: 20%, Lacerations, inversion, rupture, hematomas
Tissue: 10%, Retained tissue, accreta
Thrombin: 1%, coagulopathies
Triggering: Vital Signs and EBL
70ml/kg (5L)
6-7L in late pregnancy
HemorrhageClassification by Volume
% Blood Volume Volumes (ml)
Class I 15% 900
Class II 20-25% 1200-1500
Class III 30-35% 1800-2100
Class IV 40% 2400
HemorrhageClass I Hemorrhage (900ml)
Tachycardia < 100
Pulse pressure <30 mmHg
SBP 80-100 mmHg
Mild hypotension
Palpitations
Dizziness
HemorrhageClass II Hemorrhage (1200-1500)
HR 100-120
SBP 80-100 mmHg
Restless
Weakness
Sweating
Class III Hemorrhage (1800cc)
HR 120-160
BP <90/45 mmHg
Cold skin
Respiratory rate 30-50/min
Oliguria
Pallor
“From my cold dead hands.”
3/21/2016
9
Class IV Hemorrhage (2400cc)
HR > 120 bpm
SBP < 60 mmHg
Altered consciousness
Anuria
Absent peripheral pulse
Air hunger
Case Presentation
18 y/o G-1 P-0 at 22 weeks
IUFD with complete abruption
Large intrauterine hematoma
BP 82/20, P-128
Cold hands and feet
Urine output <10cc past 4 hours
Obstetrical Hemorrhage Protocol
Shields, LE AJOG 2015;212:272
Obstetrical Hemorrhage Protocol
Produce early intervention
Demand on-site presence of physician personnel for patient evaluation
Prevent repeated us of unsuccessful interventions
Ensure early delivery of blood products
Protocol: Maximize the Coagulation System
Prevent hypotension: Large bore IV, IV Fluids, PRBC, Fibrinogen, Platelets
Prevent Hypoxia & Acidosis: Oxygen supplementation, (Oxygen Sat >95%)
Prevent hypothermia: Warm blanket and warm IV fluids
Obstetrical Hemorrhage Protocol: Stage 1
Shields, LE AJOG 2015;212:272
foflrFoley/Urimeter
Keep Patient warm
500 ml/hr
Q 5-15 min
Rule out trauma, tissue, thrombin
3/21/2016
10
Obstetrical Hemorrhage Protocol
Shields, LE AJOG 2015;212:272
>95%
CBC, Platelet count, PT,
PTT, Fibrinogen,
electrolytes, & Creatinine
Red top tube
Type and Cross for 2 units and request 2 u of unmatched PRBCs
Intrauterine Balloon
Insert under ultrasound guidance
Inflate to 500cc with sterile water or NaCl
Use vaginal packing (iodoform or antibiotic soaked gauze) to maintain correct placement and maximize tamponade
Maximum time balloon can remain, 24 hrs
Obstetrical Hemorrhage Protocol
Shields, LE AJOG 2015;212:272
ABG, CVP, PAC, Art
line
Obstetrical Hemorrhage Protocol
Shields, LE AJOG 2015;212:272
Surgical Management
Uterine curettage
Placental bed suture
Uterine artery ligation
Repair uterine rupture
B-Lynch suture,
multiple square sutures
Hysterectomy
Stage 4 (EBL > 2400 mL)Cardiovascular CollapseProfound hypovolemic shock prior to blood loss replacement or amniotic fluid embolus
Consider surgical intervention to ensure hemostasis (hysterectomy) with aggressive blood AND factor replacement
Expeditious hemostasis is critical
3/21/2016
11
Obstetric HemorrhageMTPActivated by lead physician, (>4u PRBC given or > 10u PRBC expected in 12 hrs)
≥4 units of thawed FFP are available at all times at the blood bank
Obtain Massive Transfusion Pack in cooler, (4-4-6u PRBC, 4u FFP, 1 apheresis pack of platelets), to be sent each time more PRBC requested
Monitor CBC, PT, PTT, Fibrinogen Q 30 min
After two rounds, consider RF Factor VIIa
Massive Transfusion ProtocolStanford UniversityGoal was FFP:PRBC to 1:1.5
Pre-MTP Post MTP p-value
FFP:PRBC 1:1.8 1:1.8 0.97
Plt:PRBC 1:1.7 1:1.3 0.05
PRBC 115 minutes 71 minutes 0.02
FFP 254 minutes 169 minutes 0.04
Platelets 418 minutes 241 minutes 0.02
Mortality 45% 19% 0.02
Riskin, DJ J Am Coll Surg 2009;209:198
Be a Great Team Leader
Be confident and decisive
Look people in the eye and use their name
Repeat back orders
Confirm order are being carried out
Don’t speak to the room and assume you are being heard
Remember to express gratitude
Support Program for Patient’s Family and Staff
Timely information and reassurance
Opportunities to discuss the incident
Referrals to support services
Caring and supportive words and actions
4 Domains of Patient Safety Bundles
Readiness
Recognition and Prevention
Response
Reporting/Systems Learning
Obstetric HemorrhageReporting/Systems LearningResponse
Culture of huddles and debrief for high-risk patients and post-event debriefings
Multidisciplinary review of all stage III hemorrhages for system issues
Monitor outcomes & processes metrics in perinatal QI committee
3/21/2016
12
What is the most common reason women die from postpartum hemorrhage?
Delayed or inappropriate
correction of hypovolemia
What is the most common reason women die from postpartum hemorrhage?
Doing surgery on a patient
without knowing her
coagulation status
Severe HemorrhageKey Points
Recognize early, Triggers
mental status change (acting funny, “she ain’t quite right”),
Oxygen saturation <95%
Hypotension (SBP < 90mmHg, <85/45)
Tachycardia: >110 bpm or 15%
Oliguria: < 30cc/hr
Severe HemorrhageKey Points
Volume replacement
2 X IVF for EBL
keep SBP > 90 mmHg
Fibrinogen >100mg/dl
Hct at 24-30%
Platelets 50-100K
Temperature >95 degrees F
Keep INR < 1.5
Questions
Hemorrhage
Blood Products
Type Volume Effect/Unit
PRBC 240ml Hct 3%
Platelets 50ml 5-10,000/ml
FFP 250ml Fibrinogen 10 mg%
Cryoprecipitate 40ml Fibrinogen 10 mg%
1
Planning Surgery for
Pelvic Organ Prolapse
Bob L. Shull, M.D.
Professor of Gynecology
Department of Obstetrics and Gynecology
Scott and White Memorial Hospital and Clinic
Texas A&M Health Science Center
Temple, Texas
USA
Disclaimer
My spouse and I have no relevant
financial relationship with a
commercial interest in any of the
material contained within this
presentation.
Learning Objectives
At the completion of this session, the participant should:
1. Recognize the need for accurate assessment of
the specific pelvic support defects.
2. Understand how to evaluate 5 specific vaginal sites
• Urethra
• Bladder
• Cervix or cuff
• Cul-de-sac
• Rectum
3. Understand how to plan the surgical approach
for pelvic reconstruction
2
Genesis 11: 1-9
These are all one people and speak
one language... soon they will be able
to do anything they want! Let's mix up
their language so they will not
understand each other.
Language of Pelvic
Support Defects
• Subjective
• Inaccurate
• Non-specific
Requirements for Improvement
• Define
• Normal
• Sites to be described
• Conditions of examination
Goals
• Assessment of specific sites
• Description of support loss with
maximum stress
• Anatomic abnormalities contributing
to support loss
• Reproducible
• Understandable
• Usable
• Improves patient care
Staging
• Oncology
• Clinical
• Surgical
• Infertility
• Surgical
4
Physical Findings
Normal Physical Exam
Genital hiatus
Closed
Urethral meatus
parallel to the floor
no evidence of urethral prolapse/caruncle
Anterior compartment
Cervix/Cuff
Posterior compartment
Neuromuscular assessment of pelvic floor
Gynecologic pelvimetry
Normal Pelvic Exam
Cuff and
uterosacral
ligaments
Gynecologic
pelvimetry
5
Abnormal Pelvic Exam
At Rest Straining
Open genital
hiatus
Anterior Compartment Defects
Am J Obstet Gynecol 2002, 187:93-98.
Transverse Cystocele
Anterior Compartment & Apical Defect Post Hysterectomy Cuff Prolapse
6
Posterior Compartment Defects Posterior Compartment and Apical Defects
Perineal Descent Rectal Prolapse
Results
• Office Evaluation
• Document symptoms
• Objectively describe physical findings
Objective Clinical Evaluation
GRADEGRADE
SITE 0 1 2 3 4 COMMENTS URETHRA BLADDER CERVIX/CUFF CUL-DE-SAC RECTUM PERINEUM
SITE 0 1 2 3 4 COMMENTS URETHRA BLADDER CERVIX/CUFF CUL-DE-SAC RECTUM PERINEUM
Q-tip °deviation from horizontal Subpubic arch Resting______ < 2 finger breadths_____ Straining_____ = 2-3 finger breadths_____ = 3-4 finger breadths_____ Vaginal Atrophy Yes_____ > finger breadths_____ No_____
Q-tip °deviation from horizontal Subpubic arch Resting______ < 2 finger breadths_____ Straining_____ = 2-3 finger breadths_____ = 3-4 finger breadths_____ Vaginal Atrophy Yes_____ > finger breadths_____ No_____
7
Visceral and Sexual Function
BLADDER Urinary Incontinence
Genuine incontinence
Detrusor instability
BOWEL Anal Incontinence
Anal sphincter intact
Constipation requiring splinting
SEXUAL FUNCTION Sexually active
Desires to maintain or enhance sexual function
BLADDER Urinary Incontinence
Genuine incontinence
Detrusor instability
BOWEL Anal Incontinence
Anal sphincter intact
Constipation requiring splinting
SEXUAL FUNCTION Sexually active
Desires to maintain or enhance sexual function
YES NO COMMENTSYES NO COMMENTS
Results
Management Options
• Observation or medical therapy
• Longitudinal change in symptoms
or physical findings
• Surgical management
• Plan approach based on objective
physical findings
• Integrate intraoperative findings
• Design repair specifically for defects
Results
Long Term Follow-up Comparing
Site-specific Physical Findings
• Prognosis for success or failure
• Modification of technique
• Accurate communication with
others
At the completion of this session, the participant should:
1. Recognize the need for accurate assessment of
the specific pelvic support defects.
2. Understand how to evaluate 5 specific vaginal sites
• Urethra
• Bladder
• Cervix or cuff
• Cul-de-sac
• Rectum
3. Understand how to plan the surgical approach
for pelvic reconstruction
Learning Objectives
Bibliography
1. Shull BL: Clinical evaluation of women with pelvic support defects. Clinical Obstet Gynecol, 1993, 36:939-951.
2. Shull BL, Benn SJ, Kuehl TJ: Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome, Am J Obstet Gynecol 1994;171:1429-39.
3. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Smith ARB: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol, 1996;175:10-7
4/1/2016
1
NC OBSTETRICAL & GYNECOLOGICAL SOCIETY
NC SECTION OF THE AMERICAN COLLEGE OF
OBSTETRICIANS & GYNECOLOGISTS
MEDICAID REFORMfor North Carolina
Donny C. Lambeth
NC House of Representative
April 8, 2016
1
WHY REFORM?
2
Let’s begin by looking at
the numbers . . .
3
MEDICAID REFORM
Why Reform/Re-engineer
Increasing enrollment
4
MEDICAID REFORM
Why Reform/Re-engineer
FACT: In NC, Medicaid enrollment has
significantly outpaced population growth
trends.
5
NC MEDICAID ENROLLMENT
6
Medicaid Enrollment (10/1/15) 1,820,818
Health Choice Enrollment
(SCHIP – 10/1/15) 78,138
NC Population (7/1/14 estimate) 9,953,687
SOURCE: Division of Medical Assistance and Office of State Budget and Management websites
4/1/2016
2
NC MEDICAID ENROLLMENT
7
NC ENROLLMENT COMPARED
TO POPULATION
8
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Cu
mla
tive
% G
row
th F
om
2003
NC Medicaid NC Population
MEDICAID REFORM
Why Reform/Re-engineer
FACT: In 2009, NC spending on a per
member per month (PMPM) basis began
to trend significantly differently than the
trends in the rest of the country.
9
MEDICAID REFORM
Why Reform/Re-engineer
Legislators desired higher level of budget
predictability and confidence.
10
TOTAL NC MEDICAID SPENDINGCLAIMS, ADMINISTRATION, CONTRACTS, SETTLEMENTS,
PROGRAM INTEGRITY, TRANSFERS AND OTHER SPENDING
$2.0 $2.0 $2.4 $2.5 $2.6 $2.9 $2.8 $2.3 $2.5 $3.0 $3.1 $3.4 $3.5 $0.4 $0.4
$0.4 $0.5 $0.5 $0.4 $0.2
$0.7 $1.0
$0.8 $0.3
$0.6 $0.5 $0.5
$4.8 $5.9
$6.6 $6.6
$8.1
$8.3 $8.9
$9.2 $9.5 $9.5
$8.5 $8.3
$9.0
$1.2
$0.5 $1.6 $1.2
$-
$2.0
$4.0
$6.0
$8.0
$10.0
$12.0
$14.0
$16.0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
in B
illi
on
s
Appropriations County Share ARRA Shortfall Receipts UPL/GAP Plans
SFY 2014-15 does not include the $186 M contingency reserve budgeted
Source: NC Office of the State Controller and NCAS BD701
14 12
GENERAL FUND APPROPRIATIONS COMPARISONS2010 -11 to 2014 -15
CATEGORY 2010-11 BUDGET 2014-15 BUDGET SPENDING
INCREASE
PERCENT
CHANGE
TOTAL $ 18.958 B $ 21.069 B $ 2.111 B 11.1%
MEDICAID – State
share only
$ 2.466 B $ 3.688 B $ 1.222 B 49.6%
OTHER – State
Appropriations
$ 16.492 B $ 17.381 B $ 0.889 B 5.4%
4/1/2016
3
MEDICAID REFORM
The true picture
FACT: Medicaid increasing at a rate three
times the State’s revenue growth.
13
ACTUAL STATE SPENDING
COMPARED TO BUDGET
14
NORTH CAROLINA’S GOAL
NC desires to move . . .
FROM TOWARD
Reward for volume Reward for value
Budget uncertainty Budget predictability
Sick care Health care
Risks by State Shared Risks
15
BY CREATING A PROGRAM THAT . . .
Leverages investments NC has already
made.
Embraces both short-term and long-term
ideas.
16
BY CREATING A PROGRAM THAT . . .
Rewards Innovations.
Focuses on wellness, preventive services.
17
BY CREATING A PROGRAM THAT . . .
Provides budget predictability.
Cares for the whole person, improves access,
enhances quality care and patient satisfaction.
Increases administrative ease/efficiency.
18
4/1/2016
4
MEDICAID REFORM
The Vision
Quality, Compassionate Care – efficiently
Evolution from Fee-for-Service to
Fee-for- Health
Provider-Led Supporting Evidence-Based
Care
Improving Access Across the State
Rewards Key Performance Indicators
19
Based on a capitated risk adjusted
payment methodology with shared
incentive payments built around:
Quality, Access, Satisfaction and
Financial Metrics.
20
North Carolina Will Use a Structure
21
MEDICAID TRANSFORMATION AND
REORGANIZATION
HB372
A new care delivery system with a new
financing mechanism.
1) Beneficiaries will select a Prepaid Health Plan
(PHP)
- Provider-led Entity (PLE)
- Commercial Plan (CP)
- Statewide – up to three CPs/PLEs
- Geographically up to ten PLEs only
22
KEY ELEMENTS
2) Protects essential providers i.e., Federal
qualified health centers, free clinics, public
health departments, by requiring their
participation.
23
KEY ELEMENTS
3) Protects providers to ensure the rug is not pulled out from under them on rates by setting
rate floors.
24
KEY ELEMENTS
4/1/2016
5
4) Establishes a medical loss ratio of 88%
to direct patient care, 12% limited to
administrative overhead and profits.
5) Establishes a robust Health Information
Exchange.
25
KEY ELEMENTS
6) Creates a transition reserve as North
Carolina moves from fee-for-service
to full-risk capitation.
26
KEY ELEMENTS
7) Timeline sets Federal waiver preparation for
submission June 2016; Federal negotiations
of waiver – up to two years (June 2018), ten
PHPs have two years to finalize
organizational structure plans.
Anticipate: Go live no later than July 2020
27
KEY ELEMENTS
8) 95% of eligible Medicaid-covered lives must
be covered.
9) State will ensure coverage of every county
(3 statewide/10 regional).
28
KEY ELEMENTS
10) Limited carve-outs, except for pass through
funds for Behavioral Health, Dental Care,
Dual Eligibles.
11) Preserve pass-through funds (GAP, UNC,
VIDANT).
29
KEY ELEMENTS
12) Behavioral Health continues to enhance its
network – improving on existing care.
Capitated funds determined by State and
flow through prepaid Health Plans.
13) Creates a new State Agency (Department of
Health Benefits) under DHHS.
30
KEY ELEMENTS
4/1/2016
6
14) State establishes the benefits levels, cannot
change unless approved by Legislation.
15) State retains enrollment risks.
16) Costs targets set at two percent growth below
national average.
31
KEY ELEMENTS
1) Taking an innovative approach, North Carolina
will draw upon the best practices and advances
in models of patient care – Innovations Center.
32
What are NC Medicaid Expectations?
2) Primary Care Physicians will serve as the
“medical home” to assure improved
coordination of care and lead the
transformation.
Each beneficiary will select or will be assigned
a Primary Care Physician.
33
What are NC Medicaid Expectations?
3) Reducing dependence on high-cost sites;
instead, patients will be at home or lower cost
alternatives where they wish to be.
4) Reward more efficient models of care with a
focus on quality and access to care.
34
What are North Carolina Expectations?
5) Expand utilization of more efficient care, e.g.,
Telemedicine, medical homes, while integrating
care across all silos of providers.
6) Create competition between CPs and PLEs –
reward change in delivery of care model.
35
What are North Carolina Expectations?
Take cost out of the system – bend the cost curve.
Pay based on value – quality and cost (not volume).
Support evidence-based care.
Expand access – but only with reduced costs.
36
NC – MEDICAID
A Philosophical EvolutionFEE for SERVICE FEE for HEALTH
4/1/2016
7
Establish integrated healthcare organizations to
accept risk, deliver care, and share in rewards.
Self-govern and self-manage; providers control
their own destiny.
37
NC – MEDICAID
A Philosophical EvolutionFEE for SERVICE FEE for HEALTH
Develop robust analytical data systems to manage
care/risk.
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NC – MEDICAID
A Philosophical EvolutionFEE for SERVICE FEE for HEALTH
Reduce high-end imaging.
Reduce emergency department inappropriate
utilization.
Increase generic prescriptions.
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OPPORTUNITIES
Reduce the 30-day readmission rate.
Reduce unnecessary utilization, duplication.
Improve quality care; reduce costs.
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OPPORTUNITIES
Reduce hospital acquired infections/stays.
Enrollment of “frequent flyers” in medical homes
with aggressive care management.
Promote treatment in the lowest cost
setting/facility appropriate for care.
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OPPORTUNITIES
Eliminate silos to more efficiently integrate care.
Promote wellness and preventive care.
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OPPORTUNITIES
4/1/2016
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Improve infant mortality and high costs associated
with complicated births.
Significantly expand innovative care utilizing new
technologies.
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OPPORTUNITIES
THANK YOU
AND
QUESTIONS
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Representative Donny C. Lambeth
North Carolina House of Representatives
75th District
300 N. Salisbury Street
Raleigh, North Carolina 27603
(919) 733-7547
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