north carolina’s 646 quality demonstration national academy for state health policy’s 23 rd...
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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
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 CarolinaCommunity 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
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 HomeKey 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
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 NetworksCommunity 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
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 2010Community 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
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 CarolinaCommunity 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
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 Improvement
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
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
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 OVERVIEWNC 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
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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Intervention
Exempt
646 Counties CamdenPerquimans
Martin Tyrrell
Hertford
Dare
CurrituckPasquotank
Brunswick
NewHanover
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 AnsonRichmond
Gaston
Mecklenburg
Cabarrus
Forsyth
Davidson
Montgomery
Alleghany
Wilkes
Surry
Ashe
Catawba
Yadkin
Iredell
Clay
Polk
Caldwell
WataugaMitchell
Cherokee Macon
GrahamSwain
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
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KEY ELEMENTS OF NCCCN’s DEMONSTRATIONKEY 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.
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 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)
• 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 ONEPERFORMANCE 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)
• 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 1SHARED 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)
• 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/InformaticsData/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)
• 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/InformaticsData/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
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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