Community Care of North Carolina

2012 Overview
Medicaid challenges

 Lowering reimbursement reduces access and

increases ER usage/costs
 Reducing eligibility or benefits limited by federal
“maintenance of effort”; raises burden of
uninsured on community and providers
 The highest cost patients are also the hardest to
manage (disabled, mentally ill, etc.) ─ CCNC has
proven ability to address this challenge
 Utilization control and clinical management only
successful strategy to reining in costs overall
Community Care
Provides NC with:
 Statewide medical home and care management
system in place to address quality, utilization and
cost
 100 percent of all Medicaid savings remain in state
 A private sector Medicaid management solution
that improves access and quality of care
 Medicaid savings that are achieved in partnership
with – rather than in opposition to – doctors,
hospitals and other providers.
Key Tenets of
Community Care
 Public-private partnership
 “Managed not regulated”
 CCNC is a clinical partnership, not just a financing
mechanism
 Community-based, physician-led medical homes
 Cut costs primarily by greater quality, efficiency
 Providers who are expected to improve care must
have ownership of the improvement process
Primary Goals of
Community Care
 Improve the care of Medicaid population while
controlling costs
 A “medical home” for patients, emphasizing
primary care
 Community networks capable of managing
recipient care
 Local systems that improve management of
chronic illness in both rural and urban settings
Community Care:
“How it works”
 Primary care medical home available to 1.1 million
individuals in all 100 counties.
 Provides 4,500 local primary care physicians with
resources to better manage Medicaid population
 Links local community providers (health systems,
hospitals, health departments and other community
providers) to primary care physicians
 Every network provides local care managers (600),
pharmacists (26), psychiatrists (14) and medical
directors (20) to improve local health care delivery
Community Care:
“How it works”
 The state identifies priorities and provides
financial support through an enhanced PMPM
payment to community networks
 Networks pilot potential solutions and monitor
implementation (physician led)
 Networks voluntarily share best practice solutions
and best practices are spread to other networks
 The state provides the networks access to data
 Cost savings/ effectiveness are evaluated by the
state and third-party consultants (Mercer, Treo
Solutions).
 Community Care Networks
Alleghany
Warren Northhampton Gates r
Ashe Surry a
Stokes Rockingham Caswell Person
Hertford

Chowan
Watauga Halifax
Wilkes Yadkin Granville

Alamance
Forsyth Bertie
Guilford Orange Franklin
Durham
Caldwell Alexander Davie Nash Tyrrell
Madison Edgecombe Washington
Wake Dare
Iredell Davidson Martin
Burke Wilson
Randolph Chatham
Buncombe McDowell Catawba Rowan
Haywood Pitt Beaufort
Swain Hyde
Lincoln Johnston
Rutherford Lee Greene
Graham Henderson Cabarrus Harnett
Jackson
Gaston Stanly Wayne
Polk Cleveland Montgomery
Moore Lenoir
Cherokee Mecklenburg
Craven
Macon
Clay Pamlico
Cumberland Sampson Jones
Richmond Hoke
Union Anson
Duplin
Scotland
Onslow

Robeson Bladen
Pender

Hanover
Columbus

Brunswick

AccessCare Network Sites Community Care Plan of Eastern Carolina

AccessCare Network Counties Community Health Partners
Community Care of Western North Carolina Northern Piedmont Community Care
Community Care of the Lower Cape Fear Northwest Community Care
Carolina Collaborative Community Care Partnership for Health Management
Community Care of Wake and Johnston Counties Community Care of the Sandhills
Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont
Carolina Community Health Partnership

Source: CCNC 2012

Community Care Networks

 Are non-profit organizations that receive a per-member,

per-month (PMPM) payment from the state
 Primary care providers also receive a PMPM payment
 Provides resources needed to manage enrolled
population, reducing costs
 Central office of CCNC is also a nonprofit 501(c)(3)
 Seek to incorporate all providers, including safety net
providers
 Have Medical Management Committee oversight
 Hire care management staff
Each network has:
 Clinical Director
 A physician who is well known in the community
 Works with network physicians to build compliance with
care improvement objectives
 Provides oversight for quality improvement in practices
 Serves on the State Clinical Directors Committee
 Network Director who manages daily operations
 Care Managers to help coordinate services for
enrollees/practices
 PharmD to assist with Med management of high cost
patients
 Psychiatrist to assist in mental health integration
Current State-wide Disease
and Care Management Initiatives
 Asthma (1998 – 1st Initiative)
 Diabetes (began in 2000)
 Dental Screening and Fluoride Varnish (piloted for the state in 2000)
 Pharmacy Management
 Prescription Advantage List (PAL) - 2003
 Nursing Home Poly-pharmacy (piloted for the state 2002 - 2003)
 Pharmacy Home (2007)
 E-prescribing (2008)
 Medication Reconciliation (July 2009)
 Emergency Department Utilization Management (began with Pediatrics 2004 / Adults 2006 )
 Case Management of High Cost-High Risk (2004 in concert with rollout of initiatives)
 Congestive Heart Failure (pilot 2005; roll-out 2007)
 Chronic Care Program – including Aged, Blind and Disabled
 Pilot in 9 networks 2005 – 2007
 Began statewide implementation 2008 - 2009
 Behavioral Health Integration (began fall 2010)
 Palliative Care (began fall 2010)
Chronic Care Process
Chronic Care Program
Components

 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
Community Care’s
Informatics Center

 Informatics Center ─ Medicaid claims data

 Utilization (ED, Hospitalizations)
 Providers (Primary Care, Mental Health, Specialists)
 Diagnoses – Medications – Labs
 Costs
 Individual and Population Level Care Alerts

 Real-time data
 Hospitalizations, ED visits, provider referrals
Community Care’s
Informatics Center
 Care Management Information System (CMIS)
 Pharmacy Home
 Quality Measurement and Feedback Chart Review
System
 Informatics Center Reports on prevalence, high-
opportunity patients, ED use, performance
indicators
 Provider Portal
Provider portal in action
“Quality first” approach
leads to savings

 Recent analysis by Milliman, Inc. estimated savings

achieved by CCNC from 2007 through 2010
 Employed multiple methodologies to answer the
question: “What would costs have been without
CCNC?”
 Included data on children, adults, Aged Blind &
Disabled
 Risk adjusted to review results across similar patient
cohorts

17
“Quality first” approach also
leads to savings
Milliman’s estimate: nearly a billion dollars over a
period of 4 years

State Fiscal Year Total Annual Savings

2007 $103,000,000

2008 $204,000,000

2009 $295,000,000
2010 $382,000,000

$984,000,000

18
Cost savings estimate:
Treo Solutions

Using the unenrolled fee-for-service population, risk adjustments were made by creating a total cost of
care (PMPM) set of weights by Clinical Risk Group (CRG), with age and gender adjustments. This
weight set was then applied to the entire NC Medicaid Population. Using the FFS weight set and base
PMPM, expected costs were calculated. This FFS expected amount was compared to the actual
Medicaid spend for 2007, 2008, 2009. The difference between actual and expected spend was
considered savings attributable to CCNC. Treo Solutions, Inc., June 2011.
Cost savings estimate:
Mercer, Inc.

 Earlier studies by Mercer, Inc. estimated CCNC savings as:

State Fiscal Year Estimated Savings
2005 $77 - $81M
2006 $154 - $170M
2007 $135 - $149M
2008 $156 - $164M
2009 $186 - $194M
 Variance from Expected
Spending
Adjusting for the severity of illness of the population, total spending for CCNC enrollees
has been lower than expected each of the past 3 years.
4.0%
2.5%
2.0%

0.0%
2007 2008 2009

-2.0%

-4.0% -3.5%

-6.0% -5.4%
-5.9%
-6.6%
-6.9%
-8.0% -7.4%

-8.7%
-10.0%

-10.6%
-12.0%
Child Adult Total
Quality results
 Community Care is in the top 10 percent in US in HEDIS for
diabetes, asthma, heart disease compared to commercial
managed care.
 More than $700 million in state Medicaid savings since
2006.
 Adjusting for severity, costs are 7% lower than expected.
Costs for non-Community Care patients are higher than
expected by 15 percent in 2008 and 16 percent in 2009.
 For the first three months of FY 2011, per member per
month costs are running 6 percent below FY 2009 figures.
 For FY 2011, Medicaid expenditures are running below
forecast and below prior year (over $500 million).
 Quality HEDIS Measures

Cholesterol Control LDL <100

Cholesterol Testing
Diabetes

Blood Pressure Control <130/80

CCNC 2009
A1C Control <9.0
CCNC 2010
National Medicaid HMO HEDIS mean

A1C Testing
Cardiovascular

Cholesterol Control LDL<100

Disease

Blood Pressure Control <140/90

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Community Care Advantage

 Flexible structure that invests in the community

(rural and urban) -- provides local jobs
 Fully implemented in all 100 counties
 All the savings are retained by the State of North
Carolina
 Very low administrative costs
 Ability to manage the entire Medicaid population
(even the most difficult)
 Proven, measurable results
 Team effort by NC providers that has broad
support
Building on Success

Other payers and major employers are

interested in benefit’s of CCNC’s approach
 Medicare 646 demo (22 counties) caring for
Medicare patients
 Beacon Community (3 counties), all payers
 Multi-payer primary care demo (7 rural counties)
Medicare, Medicaid, Blue Cross and Blue Shield
of North Carolina, State Employees Health Plan
 New major employer initiative (40,000 patients)
Next Steps for CCNC

 Build out Informatics Center and Provider Portal as

a shared resource for all communities
 Add specialists to CCNC
 Develop budget and accountability model for NC
Medicaid
 Implement additional multi-payer projects
 Work with NCHA, IHI on best practices for reducing
readmissions
 Facilitate Accountable Care Organizations (ACOs)