Pr imar y Car e and CCNC: Pr imar y Car e and CCNC: T he E xpe r ie nc e of One US State T he E xpe r ie nc e of One US State T homas C. Ric ke tts, Ph.D., MPH T he Unive r sity of Nor th Car olina-Chape l Hill
Nor th Car olina � No rth Ca ro lina (NC) histo ric a lly, a po o r, so uthe rn sta te � Sinc e 1970s a “Sunb e lt” T e c hno lo g y Ce nte r � Population 8,970,000 � 48,710 sq mile s (127,000 km 2 ) � Pove r ty Rate 19% (US 17% ) � Infant De ath Rate 8.6/ 1000 (US 6.8) � 113 hospitals, 19,100 physic ians 85,000 r e giste r e d nur se s � 8,200 pr imar y c ar e physic ians � 6 Unive r sity Hospital Syste ms (CHUs) � Duke , UNC, E CU, Wa ke F o re st, Ca ro lina s Me dic a l, Missio n.
Co nte xt: Prima ry Ca re Struc ture NC Pra c titio ne rs Struc ture s Po pula tio ns � Sma ll Pra c tic e Offic e s � Priva te I nsure d (inc l � F a mily Physic ia ns � N=800 sta te e mplo ye e s) � N=3,000 � N=4.5 million � Clinic s (multispe c ia lty) � Ge ne ra l I nte rnists � Me dic a re � N=400 � N=3,000 � N=1.25 million � F e de ra l Clinic s � Pe dia tric ia ns � Me dic a id � N=50 � N=1.3 million � N=1,500 � Rura l He a lth Ce nte rs � Uninsure d � N=85 � Nurse Pra c titio ne rs � N=1.4 million � Unive rsity Clinic s � N=1,300 � Ve te ra ns � N=10 � Physic ia n Assista nts � N=200,000 � Ve te ra ns Clinic s � N=1,400 � N=8
Co nte xt: CCNC Struc ture s Pra c titio ne rs Struc ture s Po pula tio ns � Sma ll Pra c tic e Offic e s � Priva te I nsure d (inc l � F a mily Physic ia ns � N=800 sta te e mplo ye e s) � N=3,000 � N=4.5 millio n � Clinic s (multispe c ia lty) � Ge ne ra l I nte rnists � Me dic a re � N=400 � N=3,000 � N=1.25 millio n � F e de ra l Clinic s � Pe dia tric ia ns � Me dic a id � N=50 � N=1.3 million � N=1,500 � Rura l He a lth Ce nte rs � Uninsure d � N=85 � Nurse Pra c titio ne rs � N=1.4 millio n � Unive rsity Clinic s � N=1,300 � Ve te ra ns � N=10 � Physic ia n Assista nts � N=200,000 � Ve te ra ns Clinic s � N=1,400 � N=8
Me dic a id in NC � F unde d b y Sta te o f NC and US F e de ra l Go ve rnme nt � F e de r al (National) law c ontr ols, pays state s 50- 80% � Ce nte r for Me dic ar e and Me dic aid Se r vic e s (CMS applie s r ule s) � State s must c ove r some gr oups, have options for othe r � NC Ge ne r al Asse mbly c hoose s options, appr opr iate s $9 BIL L ION (63% fe de r al funds)
Me dic a id: K e y Pro g ra m fo r SPE CI AL Po pula tio ns � Sta te -F e de ra l pro g ra m to pro vide me dic a l c a re fo r lo w inc o me a nd CAT E GORI E S o f pe o ple � Wome n and c hildr e n be low 200% of pove r ty � L ow inc ome pe ople qualifie d for Me dic ar e (shar e d) � Blind and disable d � Re c ipie nts of c ash assistanc e pr ogr ams
Me dic a id Go a ls/ Me c ha nisms � T o c o ve r he a lth c a re c o sts fo r c e rta in lo w-inc o me o r disa b le d g ro ups � NOT a n insura nc e syste m fo r po o r pe o ple (CMU) � No t a unifie d na tio na l syste m, b ut a sta te -fe de ra l “pa rtne rship” � Co sts a re g ro wing fa ste r tha n Me dic a re
Co mmunity Ca re o f NC: CCNC � De ve lo pe d b y L OCAL physic ia ns in c o o pe ra tio n with e ntre pre ne uria l ST AT E b ure a uc ra t (Jim Be rnste in) � Allo we d b y CMS a s a “Wa ive r” pro g ra m � 77% o f 1.4 millio n Me dic a id e ligible s a re e nro lle d in CCNC
CCNC ke y fe a ture s � Ne twor ks of physic ians and � Pe r Me mb e r Pe r Mo nth pa yme nt to Ne two rk � $2.50 for c ase manage me nt � +$3.00 for population he alth ac tivitie s for AF DC � OR , $5-$8 for inte nsive c ase s (disable d) � Pro g ra m must de mo nstra te c o st re duc tio ns � 14 c o mmunity ne two rks, 3,500 physic ia ns in 1,200 pra c tic e s, 913,000 e nro lle d pa tie nts.
CCNC Ne two rks � Sc o pe o f Ne two rks � Smalle st: 20,386 e nr olle e s (2 r ur al c ountie s) � L ar ge st: 220,864 e nr olle e s (Spr e ad ac r oss the state in a loose ne twor k he ld toge the r by an ac ade mic syste m, UNC He alth) � L ar ge st L oc al: 103,053 e nr olle e s (foc use d on two ur ban c ountie s and one adjac e nt r ur al c ounty)
Wha t A Ne two rk Do e s � Assume s re spo nsib ility fo r prima ry c a re o f Me dic a id re c ipie nts � I de ntifie s c o stly pa tie nts a nd se rvic e s � De ve lo p a nd imple me nt pla ns to ma na g e utiliza tio n a nd c o st (e .g ., E me rg e nc y De pa rtme nt visit fo llo w up, pha rma c y use ) � Suppo rt c hro nic dise a se c a re (Dise a se Ma na g e me nt o ve ra ll, Asthma , c o ng e stive he a rt fa ilure ); � Suppo rt o ng o ing q ua lity impro ve me nt pro c e ss
CCNC Sta te / Ce ntra l I nfra struc ture � Ca re Ma na g e me nt I nfo rma tio n a nd re so urc e s � Ca se Ma na g e me nt T ra ining fo r nurse s/ MDs � Me dic a l Dire c to r/ Ne two rk Dire c to r me e ting s � Po pula tio n/ Dise a se Ma na g e me nt Suppo rt � Sta te wide a udits o f q ua lity o f c a re � De sig n a nd Suppo rt fo r ne w pilo t pro g ra ms
Sc he ma fo r CCNC Sc he ma fo r CCNC ASTHMA ASTHMA • Select targeted diseases/care processes Clinical Directors Group • Select targeted diseases/care processes DIABETES DIABETES STATEWIDE I • Review evidenced-based practice guidelines • Review evidenced-based practice guidelines PHARMACY PHARMACY • Define the program • Define the program HIGH-RISK & -COST HIGH-RISK & -COST • Establish program measures • Establish program measures ED ED HEART FAILURE HEART FAILURE Local Medical Mgmt. Comm. GASTRO-ENTERITIS FEVER GASTRO-ENTERITIS FEVER II OTITIS MEDIA DEPRESSION OTITIS MEDIA DEPRESSION • Implement state-level initiatives • Implement state-level initiatives CHILD DEVELOPMENT LOW BIRTH WEIGHT CHILD DEVELOPMENT LOW BIRTH WEIGHT • Develop local improvement initiatives • Develop local improvement initiatives ADHD CAP-C CAP-C ADHD CHRONIC CARE MENTAL HEALTH CHRONIC CARE MENTAL HEALTH III PRACTICE A PRACTICE B PRACTICE C DIABETES DISPARITIES DENTAL VARNISHING DIABETES DISPARITIES DENTAL VARNISHING OBESITY OBESITY Care Managers and CCNC quality improvement staff Care Managers and CCNC quality improvement staff support clinical management activities support clinical management activities
Pro c e ss � CCNC Clinic a l Dire c to rs � Se le c t tar ge te d dise ase with e vide nc e for e ffe c tive ne ss of inte r ve ntions � De fine PROGRAMS (diabe te s, asthma, e me r ge nc y r oom, phar mac e utic als, he ar t failur e , othe r ) � E stablish c r ite r ia for me asur e me nt � E a c h ne two rk ha s Me dic a l Dire c to r a nd Ma na g e me nt te a m tha t de te rmine s imple me nts PROGRAM � T e a m de te rmine s prio rity fo r L OCAL ne two rk o r PRACT I CE
I mpa c t o n F a mily Me dic ine Pra c tic e s (sma ll physic ia n o ffic e s) � Ave ra g e pa tie nt pa ne l pe r physic ia n—2400 pa tie nts � Ave ra g e % Me dic a re —20% (480 pa tie nts) � Ave r age % Me dic aid—9% (216 patie nts) Ye ar ly impac t of $2.50 pmpm, Me dic aid—$6,480 pe r physic ian (ave r age inc ome pe r physic ian $170,000) Othe r inc e ntive s ma y c o me in future : Me dic a re Me dic a l Ho me Pa y fo r Pe rfo rma nc e
e e db a c k Pro file s a s Pra c tic e F
CCNC—Outc o me s
E me rg e nc y De pa rtme nt E D Use ED Utilization Rate – 7/1/01 – 6/30/03 – Children < 21 years ED Utilization Rate – 7/1/01 – 6/30/03 – Children < 21 years UR Rate Per 1000 MM UR Rate Per 1000 MM Contr ols CCNC Fiscal Year Fiscal Year
E D I nitia tive ED Cost PMPM – 7/1/01 – 6/30/02 – Children < 21 years ED Cost PMPM – 7/1/01 – 6/30/02 – Children < 21 years Savings Savings Calculation Calculation (Access I PMPM – (Access I PMPM – Access II-III) x Access II-III) x ED Cost PMPM ED Cost PMPM Access II-III Enrollment Access II-III Enrollment Total Savings – ’01-’02 Total Savings – ’01-’02 $10,362,190 $10,362,190 Contr ols CCNC Fiscal Year Fiscal Year
Asthma I nitia tive Asthma I nitia tive Pediatric Asthma Hospitalization Rates Pediatric Asthma Hospitalization Rates April 2000 - December 2002 Key April 2000 - December 2002 Key Inpatient admission rate per Inpatient admission rate per 1000 member months 1000 member months
Dia b e te s—Ne two rk Co mpa riso ns
Co sts Sa ving s: Co ntro ve rsy � CCNC ha s a n a c tua ry e stima te “sa ving s” b a se d o n c o sts pe r me mb e r pe r mo nth fo r pa tie nts. � Me rc e r (priva te a c tua ry) E xtra po la te s to a ll e nro lle e s � E stimate s “Savings” of $240,000,000 (2006) on total pr ogr am c osts of $9,012,613,680 (2.67% ) � Me r c e r e stimate s dr op to $147,000,000 in 2007 � E xtr apolate s e xpe r ie nc e of c hr onic c ar e r e sults to ac ute c ar e � Othe r , c ase by c ase analysis e stimate s savings of pe r haps $30,000,000 base d on c ase -matc h me thodology
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