ORGANIZING NORTH CAROLINAS ESSENTIAL COMMUNITY PROVIDERS INTO A - - PowerPoint PPT Presentation

July 2017

ORGANIZING NORTH CAROLINA’S ESSENTIAL COMMUNITY PROVIDERS INTO A SYSTEM OF HEALTH

Providing Primary Care to the Safety-Net Uninsured

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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

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Adding Visibility to the Uninsured

Making a Case e fo for Sel elf-Deter ermination

June 2019 Statewide Health IT Initiatives Multiple Prior State Health IT Attempts and Strategies with Mixed Degrees of Success

February/June 2018 NC HIE-A Deadlines move back to June 2019

June 2018 June 2017

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

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Statewide Health IT Initiatives

Participating in Medicaid Reform

Mak Making ng a Case e fo for Sel elf-Deter ermination

June 2019 Medicaid Reform (1115 Waiver)

May 2017 – Public Input Sought on Medicaid Reform

• Listening Sessions Held

Across the State

• Written Responses

Accepted

June 2018 June 2017

RFP release

(expected)

Written RFP responses due

MCO/PLE Selection Process

Managed Medicaid Enrollment Processes Network Development and Provider Adequacy Efforts

Impact on primary care services for the safety-net uninsured

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Safety-Net as a “System of Health”

Mak Making ng a Case e fo for Sel elf-Deter ermination

June 2019 Safety-Net as a “System of Health”

June 2016 – concept first raised at Primary Care conference

Self-determined path forward … Develop advocates and beneficial partnerships

June 2018 June 2017 Statewide Health IT Initiatives Medicaid Reform (1115 Waiver)

January 2017 – SNAC members joined together to propose a solution and begin socializing the concept Better care coordination thru primary care services to the safety-net uninsured

1. Payors – attract interest from PHPs and gain concessions in terms of benefit plan design (pmpm) and coverage of whole person care 2. State – arrange support in terms of ORH technical assistance, favorable RFP requirements, and HIE use cases 3. Clinics – demonstrate on-going value by including sites in the co-creation process, delivering perceived benefits and ultimately improving the care of the communities being served

Forward progress continues to be made …

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Primary Care1 Safety-Net Providers

773 773 Se Service Si Sites s Offere red d via a a a Netwo twork rk of Affiliati ations ns

§ No North h Carolina na Association n of Free & Cha haritabl ble Clini nics (NC NCAFCC) – an association of 70 free and charitable clinics – 90 901 si sites s covering 46 cou

• unties

§ No North 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

• unties

§ 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 Health Units – 261 2612 si sites s co covering 100 co counties § Ru Rural Health Centers and Clinics (RH RHCC) - supported by state and federal funds, but not currently represented by an association – 87 87 sites covering 38 38 counties § Cr Critical Access Hospitals - 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 90 lo locatio ions coverin ing 25 co counties

Building on Collec ective e Inves estmen ents and Established ed Rel elational Equity

120 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

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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

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Primary Care to the Uninsured

44. 44.3% 3% of

• f ~1.1M Res

esiden ents Seek eeking Care e in in our Clin linic ics Are e Uninsured ed

Clinic Site Patients Served

(annually)

Percent Uninsured

Free Clinics

78,4861 100%

FQHC

471,7252 42.2%

Health Dept.

518,6463 37.2%

RHC

82,8984 13.3%

SBHC

15,744 25%

Sub- Total

1,095,655 44.3%

485,480

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 Does not accept or bill insurance companies Must see all patients regardless of their ability to pay; 26% Medicaid Responsible for 100 county strategy; provides direct primary care in > 70 counties Designation is specific to NC state-supported medical facilities 43% of the estimated 1.1M uninsured NC residents have sought care within our clinics Medicaid covers the far majority of children with insurance

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Safety-Net: Provider of Last Resort

The e Churn within the e Med edicaid Layer er Impacts the e Uninsured ed

Uninsured (11%) 1.1M* 1.8M* Medicaid (18%) Employer (48%)

Job Loss, Coverage Loss or Underinsured New Job, New Coverage and New Providers

Revolving Door of Access and Eligibility

4.9M*

Aging Out of Uninsured or Underinsured Status

1.3M* Medicare (13%)

People of All Means / Dual Eligible

10,146,788 as of July 1, 2016**

0.7M* Non-Group (7%)

*Source: KFF.org; Health Insurance Coverage of the Total Population **Source: https://www.census.gov/quickfacts/table/PST045216/37

2016 Churn Rate of 88%: + 710,000 new enrollees

• 626,000 disenrolled

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Sa Safety-Net Clinics Ser erved ed 485, 485,480 480 of the e State’ e’s ~1 ~1.1M Uninsured ed

Getting Folks ‘Insurance Ready’

People are encouraged to seek care either … through a hospital emergency department for an average cost of $1,2331 per visit in an established primary care setting within the safety-net at a cost of $40.133 per visit

• r

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/ 3 Level 3 Established Office Visit (99213) - https://dma.ncdhhs.gov/providers/programs-services/medical/federally-qualified-health-centers

55% of emergency care goes uncompensated2 44.3% of primary care patients accessing the safety-net are uninsured

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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 NC Rural Health Leadership Alliance

Providing Whole Person Care

Pr Proximity to Vulner erable e Populations Enables es Better er Coordination

Demand Signals Supply Signals

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Capabilities Under Development

Seven en Activities es Are e Under erway in Each of the e Six Med edicaid Reg egions

#

Capability Area Brief Description

1

Network Development

The safety-net has typically organized itself to satisfy an internal set of customers. New ways of organizing ourselves are required in order to effectively engage with a set of external entities and to take a more active part in Medicaid Reform.

2

Data Connectivity

Mandates for submitting encounter level data into the health information exchange (HIE) are both well-publicized and highly recognized for the desired benefits they will help to generate.

3

SDOH Measurement

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

4

Community Development

Using multiple strategies targeting the entire population (with specific attention to those who are at highest risk) has been shown to create a “dose effect.”

5

Quality Measurement

We recognize the importance of early engagement with PHP and regional health systems who will cover/serve a high percentage of the enrolled population.

6

Care Coordination

Reporting from NC HealthConnex will allow our system of care to provide “community care management” activities within our network and to target education and provide the highest likelihood of successful interventions.

7

Regional Pilots

The completion of meaningful pilots has always been seen as another step towards moving this nascent idea forward and towards its statewide 100 county strategy.

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Region One: Western

137 137 Lo Locat ations ns Ac Acro ross 19 19 Counties es Ser erving ~165,000 Ben enef eficiaries es

The current Region One provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 137 locations across 19 counties.

County Safety-Net Sites FQHC FCC LHD RHCC Avery 2 1 Buncombe 7 2 10 Burke 2 2 Caldwell 3 1 1 Cherokee 1 1 Clay 1 1 Graham 1 1 Haywood 2 1 1 Henderson 10 1 1 1 Jackson 2 1 19 1 Macon 1 2 16 1 Madison 4 1 1 McDowell 1 6 Mitchell 2 1 3 Polk 1 1 Rutherford 1 1 Swain 1 1 Transylvania 1 1 Yancey 1 1 3 Sub-Total: 39 11 62 17

Fourteen counties in this region are officially designated as rural.

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Region Two: Northwest

78 78 Lo Locat ations ns Acr cross

• ss 13 Counties

es Ser erving ~280,000 Ben enef eficiaries es

The current Region Two provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 78 locations across 13 counties. Nine of the thirteen counties in this region are officially designated as rural counties.

County Safety-Net Sites FQHC FCC LHD RHCC Alleghany 1 1 Ashe 2 4 1 Davidson 2 3 1 Davie 1 1 Forsyth 3 3 1 Guilford 6 3 5 Randolph 2 2 1 Rockingham 1 2 1 1 Stokes 2 1 Surry 1 1 Watauga 3 3 1 Wilkes 1 8 2 Yadkin 1 3 Sub-Total: 21 17 31 6

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Region Three: South-Central

70 70 Lo Locat ations ns Acr cross

• ss 12 Counties

es Ser erving ~410,000 Ben enef eficiaries es

The current Region Three provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 70 locations across 12 counties. Eight of the twelve counties in this region have been officially designated as rural.

County Safety-Net Sites FQHC FCC LHD RHCC Alexander 1 1 Anson 1 1 2 Cabarrus 2 1 3 Catawba 1 1 3 Cleveland 2 4 Gaston 11 3 Iredell 2 2 3 1 Lincoln 1 1 Mecklenburg 2 7 1 Rowan 2 1 2 Stanly 1 1 Union 1 2 3 Sub-Total: 23 16 25 6

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Region Four: North-Central

101 101 Lo Locat ations ns Acr cross

• ss 14 Counties

es Ser erving ~299,000 Ben enef eficiaries es

The current Region Four provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 101 locations across 14 counties. Seven of the fourteen counties are officially designated as rural.

County Safety-Net Sites FQHC FCC LHD RHCC Alamance 5 1 3 Caswell 3 2 Chatham 3 1 2 Durham 8 4 1 Franklin 1 1 1 Granville 1 2 Johnston 2 6 2 Nash 3 4 1 Orange 3 1 3 Person 1 2 Vance 1 1 1 Wake 8 6 11 Warren 1 1 Wilson 1 2 Sub-Total: 40 14 40 6

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Region Five: Southeastern

132 132 Lo Locat ations ns Acr cross

• ss 15 Counties

es Ser erving ~291,000 Ben enef eficiaries es

The current Region Five provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 132 locations across 15 counties. Eleven of the region’s fifteen are designated as rural counties.

County Safety-Net Sites FQHC FCC LHD RHCC Bladen 2 1 7 Brunswick 3 2 3 5 Columbus 6 2 5 Cumberland 4 1 4 Harnett 5 1 3 Hoke 1 2 2 Lee 1 2 Montgomery 1 2 2 Moore 1 1 New Hanover 1 1 5 Pender 1 6 5 Richmond 1 1 Robeson 5 8 9 Sampson 10 1 Scotland 1 1 1 2 Sub-Total: 41 8 42 37

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Region Six: Northeastern

140 140 Lo Locat ations ns Acr cross

• ss 27 Counties

es Ser erving ~230,000 Ben enef eficiaries es

The current Region Six provider network offered through the North Carolina Safety-Net Health System provides beneficiaries with access to 140 locations across 27 counties. Twenty-two of the region’s twenty-seven counties have been designated as rural.

County Safety-Net Sites FQHC FCC LHD RHCC Beaufort 2 2 Bertie 3 1 2 Camden 1 Carteret 1 1 1 Chowan 1 1 Craven 3 2 3 Currituck 1 1 Dare 2 3 Duplin 8 1 2 Edgecombe 3 3 2 Gates 2 1 Greene 7 1 Halifax 8 3 2 Hertford 3 4 Hyde 2 1 1 Jones 1 1 Lenoir 1 1 Martin 2 Northampton 2 1 Onslow 1 1 1 1 Pamlico 1 1 1 Pasquotank 1 2 1 Perquimans 1 Pitt 4 2 3 Tyrrell 2 2 Washington 1 3 1 Wayne 6 3 1 1 Sub-Total: 60 15 45 15

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Safety-Net Network Adequacy

773 773 Lo Locat ations ns Acr cross

• ss 100 Counties

es Ser erving ~1.675M Ben enef eficiaries es

Medicaid Region # of Counties Safety-Net Primary Care Sites FQHC FCC LHD RHCC CAH SBHC Sub-Total

One

19 39 11 62 17 8 # 129

Two

13 21 17 31 6 3 # 75

Three

12 23 16 25 6 6 # 70

Four

14 40 14 40 6 1 # 100

Five

15 41 8 42 37 4 # 128

Six

27 60 15 45 15 5 # 135

Sub-Total:

100 224 906 2616 87 21 90

7736

6Sub-totals for FCC and LHDs are currently

greater than the sum of their regional counts based on latest available figures

The nearby network map along with the table below speak to the coverage adequacy that has been created over decades of thoughtful investment and strong public health leadership within

• ur state. Seventy of the counties have

been designated at rural counties.

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