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North Carolina’s 646 Quality Demonstration


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North Carolina’s 646 Quality Demonstration

  1. 1. North Carolina’s 646 Quality Demonstration National Academy for State Health Policy’s 23 rd Annual State Health Policy Conference Denise Levis Hewson, RN, BSN, MSPH October 5 th , 2010, New Orleans
  2. 2. Community Care of North Carolina <ul><li>State-wide enhanced PCCCM model </li></ul><ul><li>Connects community providers (hospitals, health departments and departments of social services) with primary care physicians </li></ul><ul><li>Assures enrollees have a designated primary care medical home </li></ul><ul><li>Creates community networks to support medical homes in population management activities </li></ul>
  3. 3. Key Attributes of Our Medicaid Medical Home <ul><li>Provide 24 hour access </li></ul><ul><li>Provide or arrange for hospitalization </li></ul><ul><li>Coordinate and facilitate care for patients </li></ul><ul><li>Collaborate with other community providers </li></ul><ul><li>Participate in population management – care and disease management / prevention / quality improvement </li></ul><ul><li>Serve as single access point for patients </li></ul>
  4. 4. Community Care Networks <ul><li>Are Non-profit organizations </li></ul><ul><li>Seek to incorporate all providers, including safety net providers </li></ul><ul><li>Have Medical Management Committee oversight </li></ul><ul><li>Receive $3.72 pm/pm from the State for most enrollees </li></ul><ul><ul><li>$13.72 pm/pm for the Aged, Blind and Disabled enrollees </li></ul></ul><ul><li>Hire care management staff to work with enrollees and PCPs </li></ul><ul><li>Participating PCPs receive $2.50 pm/pm to provide a medical home and participate in Disease Management and Quality Improvement </li></ul><ul><ul><li>$5.00 pm/pm for Aged, Blind and Disabled </li></ul></ul><ul><li>NC Medicaid also pays the PCP “Fee For Service” @ 95% of Medicare </li></ul>
  5. 5. Community Care of North Carolina – Now in 2010 <ul><li>Focused on improved quality, utilization and cost effectiveness of chronic illness care </li></ul><ul><li>14 Networks with more than 4500 Primary Care Physicians (1400 medical homes) </li></ul><ul><li>Over 1,033,000 enrollees </li></ul><ul><li>NC General Assembly mandated inclusion of Aged, Blind and Disabled, and SCHIP </li></ul>
  6. 6. Community Care of North Carolina AccessCare Network Sites AccessCare Network Counties Access II Care of Western NC Access III of Lower Cape Fear Community Care of Wake and Johnston Counties Community Care of Central Carolina 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 Carolina Collaborative Comm. Care Carolina Community Health Partnership Comm. Care Partners of Gtr. Mecklenburg Northwest Community Care Network
  7. 7. Current State-wide Disease & Care Management Initiatives <ul><li>Asthma </li></ul><ul><li>Diabetes </li></ul><ul><li>Pharmacy Management (PAL, Nursing Home Polypharmacy) </li></ul><ul><li>Dental Screening and Fluoride Varnish </li></ul><ul><li>Emergency Department Utilization Management </li></ul><ul><li>Case Management of High Cost-High Risk </li></ul><ul><li>Congestive Heart Failure </li></ul><ul><li>Chronic Care Program – including Aged, Blind and Disabled </li></ul><ul><li>Rapid Cycle Quality Improvement </li></ul>
  8. 8. Chronic Care Program Components to Manage the Duals <ul><li>Enrollment/Outreach </li></ul><ul><li>Screening/Assessment/Care Plan </li></ul><ul><li>Risk Stratification/ Identify Target Population </li></ul><ul><li>Patient Centered Medical Home </li></ul><ul><li>Transitional Support </li></ul><ul><li>Pharmacy Home – Medication Reconciliation, Polypharmacy & PolyPrescribing </li></ul><ul><li>Care Management </li></ul><ul><li>Mental Health Integration </li></ul><ul><li>Informatics Center </li></ul><ul><li>Self Management of Chronic Disease </li></ul>
  9. 9. NC POPULATION OVERVIEW <ul><li>There are approximately 1.5 M Medicaid eligibles </li></ul><ul><li>Over 1,033,000 enrolled in Community Care </li></ul><ul><li>There are 280,478 duals in NC (Aug 2010) </li></ul><ul><li>80,845 duals are enrolled in Community Care </li></ul><ul><li>There are 19,923 duals enrolled with a 646 practice </li></ul><ul><li>925 providers in 197 practices signed 646 agreements with in 26 counties by January 31, 2010 </li></ul><ul><li>Estimate to have 30,000 potential 646 patients for year 1 </li></ul>
  10. 10. Intervention Exempt 646 Counties Camden Perquimans Martin Tyrrell Hertford Dare Currituck Pasquotank Brunswick New Hanover Pender Cumberland Warren Northampton Halifax Nash Wayne Duplin Edgecombe Pitt Greene 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 Stokes Rockingham Guilford Randolph Union Anson Richmond Gaston Mecklenburg Cabarrus Forsyth Davidson Montgomery Alleghany Wilkes Surry Ashe Catawba Yadkin Iredell Clay Polk Caldwell Watauga Mitchell Cherokee Macon Graham Swain Jackson Haywood Madison Rutherford McDowell Yancey Avery Burke Alexander Transylvania Henderson Buncombe Cleveland Lincoln Rowan Moore Scotland Lee Durham Wilson Lenoir Beaufort Craven Onslow Holdouts Updated: October 1, 2009
  11. 11. KEY ELEMENTS OF NCCCN ’ s DEMONSTRATION <ul><li>During years one and two, NCCCN will manage approximately 30,000 dually-eligible beneficiaries who receive care from 198 practices in 26 counties. </li></ul><ul><li>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. </li></ul><ul><li>During years three to five, NCCCN will manage an estimated 180,000 Medicare and dually-eligible beneficiaries. </li></ul>
  12. 12. COMPARISON GROUP <ul><li>A Medicare beneficiary receiving a qualifying service from a primary care practice in a comparison county. </li></ul><ul><li>For comparison purposes, RTI selected 78 counties in 5 states that matched the characteristics of North Carolina’s 26 intervention counties: </li></ul><ul><ul><li>Georgia (18 counties) </li></ul></ul><ul><ul><li>Kentucky (19 counties) </li></ul></ul><ul><ul><li>South Carolina (12 counties) </li></ul></ul><ul><ul><li>Tennessee (19 counties) </li></ul></ul><ul><ul><li>Virginia (20 counties) </li></ul></ul>
  13. 13. PERFORMANCE MEASURES YEAR ONE <ul><li>Diabetes Care (four measures) </li></ul><ul><li>Heart Health – Congestive Heart Failure (five measures) </li></ul><ul><li>Ischemic Vascular Disease (three measures) </li></ul><ul><li>Hypertension (one measure) </li></ul><ul><li>Diabetes and Hypertension (one measure) </li></ul><ul><li>Post Myocardial Infarction (one measure) </li></ul><ul><li>Transitional Care (one measure) </li></ul>
  14. 14. SHARED SAVINGS – YEAR 1 <ul><li>External evaluators will determine cost savings based on comparison states </li></ul><ul><li>Savings determined by comparing actual versus target expenditures </li></ul><ul><li>Performance metrics will be determined via administrative claims data and chart reviews </li></ul><ul><li>A minimum savings threshold will be identified before sharing can occur </li></ul><ul><li>In year one, 50% savings is contingent on meeting performance metrics (50% of shared savings not contingent on meeting metrics) </li></ul>
  15. 15. Data/Informatics <ul><li>Use of claims-derived data for population management and care coordination </li></ul><ul><li>Quality measurement with claims data and chart review data </li></ul><ul><li>(Couple of examples to follow) </li></ul>
  16. 16. 80 data elements reported quarterly on ALL ABD recipients: Demographics Diagnoses Spending by category Use of ancillary services Utilization Priority scoring
  17. 17.
  18. 18. Annual Chart Review, Practice Report with Benchmarks
  19. 19.
  20. 20. Data/Informatics <ul><li>Issues for 646 </li></ul><ul><li>Key missing data for duals in our Medicaid claims data source </li></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>Pharmacy! (contracting with Surescripts as additional datasource) </li></ul></ul><ul><li>Still awaiting data from CMS (as of 9/10/2010) </li></ul><ul><ul><li>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 </li></ul></ul>