North Carolina’s 646 Quality Demonstration

National Academy for State Health Policy’s23rd Annual State Health Policy Conference

Denise Levis Hewson, RN, BSN, MSPHOctober 5th, 2010, New Orleans

Community Care of North Carolina

State-wide enhanced PCCCM model Connects community providers (hospitals, health

departments and departments of social services) with primary care physicians

Assures enrollees have a designated primary care medical home

Creates community networks to support medical homes in population management activities

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Key Attributes of Our Medicaid Medical Home

Provide 24 hour access Provide or arrange for hospitalization Coordinate and facilitate care for patients Collaborate with other community providers Participate in population management – care and

disease management / prevention / quality improvement Serve as single access point for patients

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Community Care Networks Are Non-profit organizations Seek to incorporate all providers, including safety net providers Have Medical Management Committee oversight Receive $3.72 pm/pm from the State for most enrollees

$13.72 pm/pm for the Aged, Blind and Disabled enrollees Hire care management staff to work with enrollees and PCPs Participating PCPs receive $2.50 pm/pm to provide a medical home

and participate in Disease Management and Quality Improvement $5.00 pm/pm for Aged, Blind and Disabled

NC Medicaid also pays the PCP “Fee For Service” @ 95% of Medicare

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Community Care of North Carolina – Now in 2010

Focused on improved quality, utilization and cost effectiveness of chronic illness care

14 Networks with more than 4500 Primary Care Physicians (1400 medical homes)

Over 1,033,000 enrollees NC General Assembly mandated inclusion of Aged,

Blind and Disabled, and SCHIP

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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

Community Care of North Carolina

Carolina Collaborative Comm. CareCarolina Community Health Partnership

Comm. Care Partners of Gtr. MecklenburgNorthwest Community Care Network

Community Care of Central Carolina

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Current State-wideDisease & Care Management Initiatives

Asthma Diabetes Pharmacy Management (PAL, Nursing Home Polypharmacy) Dental Screening and Fluoride Varnish Emergency Department Utilization Management Case Management of High Cost-High Risk Congestive Heart Failure Chronic Care Program – including Aged, Blind and Disabled

Rapid Cycle Quality Improvement7

Chronic Care Program Components to Manage the Duals

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

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NC POPULATION OVERVIEW There are approximately 1.5 M Medicaid eligibles Over 1,033,000 enrolled in Community Care There are 280,478 duals in NC (Aug 2010) 80,845 duals are enrolled in Community Care There are 19,923 duals enrolled with a 646 practice 925 providers in 197 practices signed 646 agreements

with in 26 counties by January 31, 2010 Estimate to have 30,000 potential 646 patients for year 1

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InterventionExempt

646 Counties CamdenPerquimans

Martin Tyrrell

Hertford

Dare

CurrituckPasquotank

Brunswick

NewHanover

Pender

Cumberland

Warren Northampton

Halifax

Nash

Wayne

Duplin

Edgecombe

PittGreene

Bertie

Jones

Gates

Carteret

Pamlico

Washington

Hyde

Chowan

Robeson

Columbus

Bladen

Sampson

Person

Hoke

Harnett

Granville

Wake

Johnston

Vance

Franklin

Caswell

Alamance

Chatham

Orange

Davie

Stanly

StokesRockingham

Guilford

Randolph

Union AnsonRichmond

Gaston

Mecklenburg

Cabarrus

Forsyth

Davidson

Montgomery

Alleghany

Wilkes

SurryAshe

Catawba

Yadkin

Iredell

Clay

Polk

Caldwell

WataugaMitchell

Cherokee Macon

GrahamSwain

Jackson

Haywood

Madison

Rutherford

McDowell

Yancey

Avery

Burke

Alexander

Transylvania

Henderson

Buncombe

Cleveland

LincolnRowan

Moore

Scotland

Lee

Durham

Wilson

Lenoir

Beaufort

Craven

Onslow

Holdouts

Updated: October 1, 2009

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KEY ELEMENTS OF NCCCN’s DEMONSTRATION

During years one and two, NCCCN will manage approximately 30,000 dually-eligible beneficiaries who receive care from 198 practices in 26 counties.

At the beginning of year three, an estimated 150,000 Medicare-only beneficiaries who will receive care from those practices will be added to the demonstration.

During years three to five, NCCCN will manage an estimated 180,000 Medicare and dually-eligible beneficiaries.

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COMPARISON GROUP• A Medicare beneficiary receiving a qualifying service from a primary

care practice in a comparison county.• For comparison purposes, RTI selected 78 counties in 5 states that

matched the characteristics of North Carolina’s 26 intervention counties:◦ Georgia (18 counties)◦ Kentucky (19 counties)◦ South Carolina (12 counties)◦ Tennessee (19 counties)◦ Virginia (20 counties)

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PERFORMANCE MEASURES YEAR ONE

• Diabetes Care (four measures)• Heart Health – Congestive Heart Failure (five measures)• Ischemic Vascular Disease (three measures)• Hypertension (one measure)• Diabetes and Hypertension (one measure)• Post Myocardial Infarction (one measure)• Transitional Care (one measure)

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SHARED SAVINGS – YEAR 1• External evaluators will determine cost savings based on

comparison states • Savings determined by comparing actual versus target

expenditures• Performance metrics will be determined via administrative claims

data and chart reviews• A minimum savings threshold will be identified before sharing can

occur • In year one, 50% savings is contingent on meeting performance

metrics (50% of shared savings not contingent on meeting metrics)

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Data/Informatics• Use of claims-derived data for population management and care coordination• Quality measurement with claims data and chart review data

(Couple of examples to follow)

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80 data elements reported quarterly on ALL ABD recipients: Demographics DiagnosesSpending by category Use of ancillary servicesUtilization Priority scoring16

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Annual Chart Review, Practice Report with Benchmarks

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Data/InformaticsIssues for 646• Key missing data for duals in our Medicaid claims data source

• No crossover of claims into our system if copayment has been met or claim not submitted to Medicaid (can’t see hospital readmissions; can’t reliably identify whether labs or other services received for QM purposes)• Pharmacy! (contracting with Surescripts as additional datasource)

•Still awaiting data from CMS (as of 9/10/2010)•As far as we understand, the data we receive will be for patients touched PRIOR to 10/1/09. So we may have significant ongoing issues about data completeness for the 646 intervention population

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