Transcript Document

North Carolina’s 646 Quality
Demonstration
National Academy for State Health Policy’s
23rd Annual State Health Policy Conference
Denise Levis Hewson, RN, BSN, MSPH
October 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
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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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Community Care of North Carolina
AccessCare Network Sites
AccessCare Network Counties
Access II Care of Western NC
Access III of Lower Cape Fear
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Community Health Partners
Northern Piedmont Community Care
Carolina Collaborative Comm. Care
Carolina Community Health Partnership
Partnership for Health Management
Northwest Community Care Network
Comm. Care Partners of Gtr. Mecklenburg
Southern Piedmont Community Care Plan
Community Care of Wake and Johnston Counties
Community Care Plan of Eastern NC
Community Care of Central Carolina
Sandhills Community Care Network
Current State-wide
Disease & Care Management Initiatives
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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 Improvement
Chronic Care Program Components to Manage
the Duals
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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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646 Counties
Ashe Alleghany
Surry
Rockingham
Stokes
Caswell
Warren
Granville
Vance
Person
Northampton
Gates
Hertford
Halifax
Watauga Wilkes Yadkin
Bertie
Orange
Mitchell
Franklin
Forsyth Guilford Alamance
Avery
Caldwell
Durham
Nash Edgecombe
Alexander
Washington
Dare
Davie
Madison Yancey
Martin
Tyrrell
Davidson
Iredell
Wake
Randolph
Burke
Wilson
Buncombe McDowell
Catawba
Chatham
Pitt
Beaufort
Rowan
Hyde
Haywood
Johnston
Greene
Swain
Rutherford
Lincoln
Lee
Cabarrus
Graham
Montgomery
Jackson
Henderson
Gaston
Harnett
Lenoir
Polk
Cleveland
Stanly
Wayne
Craven
Moore
Pamlico
Mecklenburg
Cherokee
Macon
Transylvania
Cumberland
Clay
Jones
Richmond Hoke
Sampson
Union
Anson
Duplin
Onslow
Scotland
Carteret
Robeson
Exempt
Intervention
Pender
Columbus
Holdouts
Brunswick
Updated: October 1, 2009
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Bladen
New
Hanover
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:
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Georgia (18 counties)
Kentucky (19 counties)
South Carolina (12 counties)
Tennessee (19 counties)
Virginia (20 counties)
PERFORMANCE MEASURES YEAR ONE
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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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Chronic Care/ 646 Patient Database
80 data elements reported quarterly on ALL ABD recipients:
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Demographics
Spending by category
Utilization
Diagnoses
Use of ancillary services
Priority scoring
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Annual Chart Review, Practice Report with Benchmarks
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Provider Portal Patient Medication List
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Data/Informatics
Issues 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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