Community Care of NC
“B
Building
ildi “Accountable
“A
t bl Care”
C ” Using
U i
Public Programs- lessons learned
L. Allen Dobson ,Jr. MD FAAFP
President
NC Community Care Networks, Inc
Vice President
Carolinas Healthcare System
A Move Toward Accountable Care
Care-what’s needed?
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An Imperative to Act (sometimes a crisis or mandate is
good)
Uniformity of Effort and Standard Measures of Success
An Open Process and Structure (new partnerships)
Build an advanced primary care system
New collaborative organizationsorganizations-”virtual health systems”
Willingness to Share best practice ( collaboration) and
share data (transparency)
Must balance (target) cost and quality efforts
Align incentives (new payment options)
Community Care of North Carolina
Now in 2010
 Focuses on improved quality, utilization and cost
effectiveness
 14 not for profit regional Networks with more than 4200
Primary Care Physicians (1350 medical homes) + all
NC Hospitals and other providers
 over 1,000,330 Medicaid enrollees
 Now inclusion of Aged Blind and Disabled and SCHIP
 50,000 uninsured
 Major Medicare 646 demo ( 30,000 duals and 180,000
Medicare)
HOME
 New Partnership for SEHP
NEXT
LAST
C
Community
it Care
C
Networks:
N t
k
 Non-profit organizations
 Includes all providers( medical homes) including
safety net providers
 Medical management
g
committee
 Receive $3.00/$8.00 PM/PM from the State
 Hire/pay for care managers/medical management
staff to work with PCPs
 PCP also get $2.50/$5.00
$2 50/$5 00 PMPM to serve as
medical home and to participate in DM
 NC Medicaid p
pay
y 95% of Medicare FFS for PC
and 85% others
HOME
NEXT
LAST
646 Counties
Ashe Alleghany
Surry
Rockingham
Stokes
Caswell
Warren
Granville
Vance
Person
Northampton
Gates
Hertford
Halifax
Watauga Wilkes Yadkin
Bertie
Orange
Forsyth Guilford Alamance
Mitchell
Franklin
Avery
Caldwell
Durham
Nash Edgecombe
Dare
Alexander
Davie
Washington
Madison Yancey
Martin
Tyrrell
Davidson
Iredell
Wake
Randolph
Burke
Wilson
Buncombe McDowell
Catawba
Pitt
Beaufort
Chatham
Rowan
Hyde
Haywood
Greene
Johnston
Swain
Rutherford
Lincoln
Lee
Cabarrus
Graham
Montgomery
Jackson
Henderson
Gaston
Lenoir
Harnett
Stanly
y
Wayne
y
Polk
Cleveland
Craven
Pamlico
M
Moore
Mecklenburg
Cherokee
Macon
Transylvania
Cumberland
Clay
Jones
Richmond Hoke
Sampson
Union
Anson
Duplin
Onslow
Carteret
Scotland
Robeson
Exemptt
E
Intervention
Bladen
Pender
Columbus
Holdouts
Brunswick
Updated: October 1, 2009
New
Hanover
CHARACTERISTICS OF THE 646
POPULATION (dual)
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•
50% will have 3 or more chronic conditions
75% will
ill hhave hhypertension
t i
33% will have a mental health condition
40% will
ill have
h
diabetes
di b t
25% will have heart disease
20% will
ill hhave chronic
h i obstructive
b t ti pulmonary
l
di
disease
40% will have gone to the emergency room at least once during
the year
th
25% will have been hospitalized at least once during the year
Each
E h dual
d l will
ill have
h
an average off 7.88 prescriptions
i i
per monthh
The Big Picture: It all Starts with Data
Pharmacy
Claims
Medical
Claims
Audit Data
Case
Manager
Input
(CMIS)
Pharmacist
Input
(Pharmacy
Home)
Real-time
Ph
Pharmacy
(Surescripts)
Real-time
hospital/
ED census
L b
Labs
INFORMATICS
CENTER
Practice and
Hospital
EHR
Then Technical, Analytical and Educational Support
Predictive
Models
Applications
Reporting
R
ti
Services
Analytics
 Network Area Administrator (NAM)
Quality Improvement Coordinator (QI)
Coordinator (QI)
E‐prescribing/HIT Facilitator (eRx)
p
( )
Expert Users (EU)
Data Analytics: Targeted Interventions
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Ex: KBRKBR-Funded Stroke Prevention
Initiative
Number of non-dual
patients with HTN
+ poor medication adherence
+ DM, CHD, or IVD
non-dual HTN + CHD/IVD with
poor medication adherence
31,996
12,888
6,129
1,244
C
Community
it Care
C off North
N th Carolina
C li
Cost Savings
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Cost - $8$8-20 Million yearly (state)
(Cost of
(Cos
o Co
Community
u y Ca
Caree Operations)
Ope a o s)
Compared to Prior Yr ( net of costs)
 Savings
Sa ings - $ 60 million SFY03
 Savings - $ 124 million SFY04
 Savings
Savingsg - $ 81 million SFY05
 Savings
Savings-- $ 161 million SFY06
 Savings
Savings-- $142 million SFY 07
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Total AFDC 03
03--07: $ 568 Million
NC Medicaid Administrative costs only 6%!
(Mercer Cost Effectiveness Analysis – AFDC only for Inpatient, Outpatient, ED, Physician Services, Pharmacy, Administrative Cost
Costs,
s, Other
Other))
ABD Savings SFY 05-07 additional $ 400 million- Mercer
Lessons Learned: Local Organization
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Primary Care is foundational
A larger population and geographically defined area
allows for better community dialog and system
development
Community based not for profits allows for clinical
partnership without financial integration
S lf organized
Self
i d ( flexible)
fl ibl ) local
l
l entities
titi essential
ti l for
f
local buybuy-in
Physician leadership and engagement needed
Local transparency of results needed for
improvement
p
Lessons Learned: Leadership and
Data
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A trusted entity ( statestate-wide) needed to
serve as convener
convener, collaborator and to
provide shared services
Data aggregation ( clinically enhanced
claims)-- analytics and decision support
claims)
Actionable (patient specific) data back to
communities
Technical assistance and best practice
sharing
Lessons Learned: Payment Reform
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We use FFS plus pmpm for pcps
Networks get pmpm for advance
provide accountabilityy
services and to p
Administrative support and clinical
support/ease important to docs
No p4p or shared savings yet but in
646 plan
No bundling yet in NC
Challenges and Research
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Controls in a rapidly changing environment ( need
for a new method)
How big a population is needed
What
at a
are
e tthe
e success ccharacteristics
a acte st cs o
of local
oca
organizations
Balancing public interest and local system
d
development
l
t with
ith natural
t l competitive
titi iinterest
t
t
among providers
Balancing costs savings with quality enhancement
efforts (what is the sweet spot)