ORGANIZING NORTH CAROLINA’S ESSENTIAL COMMUNITY PROVIDERS INTO A SYSTEM OF HEALTH Providing Primary Care to the Safety-Net Uninsured July 2017
Agenda Sustaining Progres ess Towards a Shared ed Goal 1. Setting the Context: External Timelines Impacting Our Efforts a. Tracking the Health Status of the Uninsured Page 3 b. Participating in Medicaid Reform Page 4 c. Safety-Net as a “System of Health” Page 5 2. Quick Review: North Carolina’s Safety-Net Health System (NCSNHS) a. Inventorying Statewide Primary Care Locations Pages 6 b. Mapping Primary Care Safety-Net Locations Page 7 c. Articulating the NCSNHS Value Proposition: i. Providing Primary Care to the Uninsured Page 8 ii. Addressing Churn Rates Within Medicaid Page 9 iii. Changing Behaviors, i.e. Getting Folks Insurance-Ready Page 10 iv. Providing Total Person Care Page 11 3. Capabilities Under Development Page 12 4. Safety-Net Coverage by Medicaid Region Pages 13-19 Page 2
Adding Visibility to the Uninsured Making a Case e fo for Sel elf-Deter ermination June 2017 June 2018 June 2019 Statewide Health IT Initiatives Multiple Prior State Health IT Attempts and February/June 2018 NC HIE-A Deadlines move back to June 2019 Strategies with Mixed Degrees of Success The North Carolina Health Information Exchange Authority (NC HIE-A) created in 2015. The state believes that making demographic and clinical information available to providers will improve care coordination . The legislation requires certain entities, as a condition of receiving state funds , to submit “demographic and clinical information.” Source: April 2017 Report from the NCIOM Task Force on All-Payer Claims Database, “Claims Data to Improve Health in North Carolina” at www.nciom.org Page 3
Participating in Medicaid Reform Mak Making ng a Case e fo for Sel elf-Deter ermination June 2017 June 2018 June 2019 Statewide Health IT Initiatives Medicaid Reform (1115 Waiver) Network Development and Provider Adequacy Efforts May 2017 – Public Input Sought on Managed Medicaid Enrollment Processes Medicaid Reform RFP release Listening Sessions Held • (expected) Across the State Impact on primary Written Responses • care services for Accepted the safety-net MCO/PLE Written RFP uninsured responses due Selection Process Page 4
Safety-Net as a “System of Health” Mak Making ng a Case e fo for Sel elf-Deter ermination June 2017 June 2018 June 2019 Statewide Health IT Initiatives Medicaid Reform (1115 Waiver) Safety-Net as a “System of Health” Develop advocates and beneficial partnerships June 2016 – concept 1. Payors – attract interest from PHPs Better care first raised at Primary and gain concessions in terms of coordination thru Care conference benefit plan design (pmpm) and primary care coverage of whole person care services to the January 2017 – safety-net 2. State – arrange support in terms of SNAC members joined uninsured ORH technical assistance, favorable together to propose a RFP requirements, and HIE use cases solution and begin socializing the concept 3. Clinics – demonstrate on-going value Self-determined by including sites in the co-creation path forward … process, delivering perceived benefits Forward progress and ultimately improving the care of continues to be made … the communities being served Page 5
Primary Care 1 Safety-Net Providers Building on Collec ective e Inves estmen ents and Established ed Rel elational Equity 773 773 Se Service Si Sites s Offere red d via a a a Netwo twork rk of Affiliati ations ns NCAFCC) – an association of 70 free and § North No h Carolina na Association n of Free & Cha haritabl ble Clini nics (NC 90 1 si charitable clinics – 90 sites s covering 46 cou ounties North No h Carolina na Communi unity Health h Center Association n (NC NCCHCA) – an association of 38 Federally § Qualified Health Centers – 224 224 si sites s covering 85 cou ounties No North h Carolina na Association n of Local Health h Di Directors (NC NCALHD) D) – an association of primary care and § dental clinics and other public health services, such as family planning, operated by local Public 261 2 si Health Units – 261 sites s co covering 100 co counties Rural Health Centers and Clinics (RH Ru RHCC) - supported by state and federal funds, but not currently § represented by an association – 87 87 sites covering 38 38 counties § Critical Access Hospitals - Cr Cr Critical access hospitals are a vital part of the health system for many ru rural al communiti ties es. With thout t cri riti tical al ac acces ess hospital als, res esiden ents ts of th thes ese e communiti ties es would lose e ac access to heal alth ca care - 21 21 sites serving 20 20 counties No North h Carolina na Scho hool Based d Health h Allianc nce (NC NCSBHA) – supporting accessible, affordable, quality § health care in school-based and school-linked health centers and providing technical assistance and advocacy for the NC school health centers at a local, state, and national level – 90 lo 90 locatio ions coverin ing 25 co counties 1 20 Collaborative Networks of multiple local partners also integrate medical, preventative, community, social, and economic resources to achieve collective outcomes through a coordinated system of care in 45 counties Page 6 Page 19 Page 6
Mapping the Statewide Safety-Net Cover erage e of Six Med edicaid Reg egions Ser erving and Estimated ed 1.675M 45 Page 3 Page 7 Page 7
Primary Care to the Uninsured 44. 44.3% 3% of of ~1.1M Res esiden ents Seek eeking Care e in in our Clin linic ics Are e Uninsured ed Clinic Percent Patients Served Site Uninsured (annually) Free Does not accept or bill 78,486 1 100% Clinics insurance companies Must see all patients FQHC 471,725 2 42.2% regardless of their ability to pay; 26% Medicaid Health Responsible for 100 county 518,646 3 37.2% Dept. strategy; provides direct primary care in > 70 counties Designation is specific to RHC 82,898 4 13.3% NC state-supported medical facilities Medicaid covers the far 15,744 25% SBHC majority of children with insurance 44.3% Sub- 43% of the estimated 1.1M uninsured NC 1,095,655 residents have sought care within our Total 485,480 clinics Sources: 1. 2015 NCAFCC Annual Outcomes Survey 2. 2015 Federal Data Report for NC Health Centers 3. NC LHD Statistical Data Summary Report SFY 2015 4. Rural Health Centers based on SFY 2017 Applications 5. 52 NC SBHCs participated in SBHA national census 2013-14 Page 8
Safety-Net: Provider of Last Resort The e Churn within the e Med edicaid Layer er Impacts the e Uninsured ed 10,146,788 as of July 1, 2016** 0.7M* Non-Group (7%) Employer (48%) 4.9M* Job Loss, Coverage Loss or New Job, New Coverage and Underinsured New Providers 1.3M* Medicare (13%) Aging Out of Uninsured or People of All Means / Dual Eligible Underinsured Status Uninsured (11%) 1.1M* 2016 Churn Rate of 88%: Revolving Door of Access and Eligibility 1.8M* Medicaid (18%) + 710,000 new enrollees - 626,000 disenrolled 0 *Source: KFF.org; Health Insurance Coverage of the Total Population **Source: https://www.census.gov/quickfacts/table/PST045216/37 Page 9
Getting Folks ‘Insurance Ready’ Sa Safety-Net Clinics Ser erved ed 485, 485,480 480 of the e State’ e’s ~1 ~1.1M Uninsured ed People are encouraged to seek care either … through a hospital emergency department 55% of emergency care goes uncompensated 2 for an average cost of $1,233 1 per visit or in an established primary care setting within the safety-net at a cost of $40.13 3 per visit 44.3% of primary care patients accessing the safety-net are uninsured 1 blog.bcbsnc.com/2014/04/5-emergency-room-myths-busted/ 2 https://www.acep.org/news-media-top-banner/the-uninsured--access-to-medical-care/ Page 10 3 Level 3 Established Office Visit (99213) - https://dma.ncdhhs.gov/providers/programs-services/medical/federally-qualified-health-centers Page 10
Providing Whole Person Care Proximity to Vulner Pr erable e Populations Enables es Better er Coordination Demand Signals Supply Signals NC Rural Health Leadership Alliance Demonstrated quality of care through health gains outcomes Social Drivers of Health: 1. Economic Stability 2. Education 3. Social and Community Context 4. Health and Health Care 5. Neighborhood and Built Environment Page 11 Page 11
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