Pr imar y Car e and CCNC: Pr imar y Car e and CCNC: T he - - PowerPoint PPT Presentation

Pr imar y Car e and CCNC: T he E xpe r ie nc e of One US State Pr imar y Car e and CCNC: 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

• lina-Chape l Hill

Nor th Car

• lina

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

• 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

F

a mily Physic ia ns

N=3,000 Ge ne ra l I

nte rnists

N=3,000 Pe dia tric ia ns N=1,500 Nurse Pra c titio ne rs N=1,300 Physic ia n Assista nts N=1,400

Struc ture s

Sma ll Pra c tic e Offic e s N=800 Clinic s (multispe c ia lty) N=400 F

e de ra l Clinic s

N=50 Rura l He a lth Ce nte rs N=85 Unive rsity Clinic s N=10 Ve te ra ns Clinic s N=8

Po pula tio ns

Priva te I

nsure d (inc l sta te e mplo ye e s)

N=4.5 million Me dic a re N=1.25 million Me dic a id N=1.3 million Uninsure d N=1.4 million Ve te ra ns N=200,000

Co nte xt: CCNC Struc ture s

Pra c titio ne rs

F

a mily Physic ia ns

N=3,000 Ge ne ra l I

nte rnists

N=3,000 Pe dia tric ia ns N=1,500 Nurse Pra c titio ne rs N=1,300 Physic ia n Assista nts N=1,400

Struc ture s

Sma ll Pra c tic e Offic e s N=800 Clinic s (multispe c ia lty) N=400 F

e de ra l Clinic s

N=50 Rura l He a lth Ce nte rs N=85 Unive rsity Clinic s N=10 Ve te ra ns Clinic s N=8

Po pula tio ns

Priva te I

nsure d (inc l sta te e mplo ye e s)

N=4.5 millio n Me dic a re N=1.25 millio n Me dic a id N=1.3 million Uninsure d N=1.4 millio n Ve te ra ns N=200,000

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

• ls, 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

• ups, have options

for

• the r

NC Ge ne r

al Asse mbly c hoose s options, appr

• pr

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

• w 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

• gr

ams

Me dic a id Go a ls/ Me c ha nisms

T

• 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

• lle e s (2 r

ur al c ountie s)

L

ar ge st: 220,864 e nr

• lle e s (Spr

e ad ac r

• ss 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

• c al: 103,053

e nr

• lle e s (foc use d on

two ur ban c ountie s and

• ne 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

• 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

Clinical Directors Group STATEWIDE

• Select targeted diseases/care processes
• Review evidenced-based practice guidelines
• Define the program
• Establish program measures
• Select targeted diseases/care processes
• Review evidenced-based practice guidelines
• Define the program
• Establish program measures

I

ASTHMA ASTHMA DIABETES DIABETES PHARMACY PHARMACY

HIGH-RISK & -COST HIGH-RISK & -COST

ED ED

Local Medical Mgmt. Comm.

• Implement state-level initiatives
• Develop local improvement initiatives
• Implement state-level initiatives
• Develop local improvement initiatives

PRACTICE A PRACTICE B PRACTICE C Care Managers and CCNC quality improvement staff support clinical management activities Care Managers and CCNC quality improvement staff support clinical management activities

III II

GASTRO-ENTERITIS GASTRO-ENTERITIS OTITIS MEDIA OTITIS MEDIA CHILD DEVELOPMENT CHILD DEVELOPMENT ADHD ADHD FEVER FEVER DEPRESSION DEPRESSION LOW BIRTH WEIGHT LOW BIRTH WEIGHT CAP-C CAP-C CHRONIC CARE CHRONIC CARE

HEART FAILURE HEART FAILURE

MENTAL HEALTH MENTAL HEALTH DIABETES DISPARITIES DIABETES DISPARITIES DENTAL VARNISHING DENTAL VARNISHING OBESITY OBESITY

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

• om, 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

Pra c tic e Pro file s a s F e e db a c k

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 Fiscal Year Fiscal Year Contr

• ls

CCNC

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

ED Cost PMPM ED Cost PMPM Fiscal Year Fiscal Year

Savings Calculation Savings Calculation

(Access I PMPM – Access II-III) x Access II-III Enrollment (Access I PMPM – Access II-III) x Access II-III Enrollment Total Savings – ’01-’02 $10,362,190 Total Savings – ’01-’02 $10,362,190 Contr

• ls

CCNC

Asthma I nitia tive Asthma I nitia tive

Pediatric Asthma Hospitalization Rates Pediatric Asthma Hospitalization Rates

April 2000 - December 2002 April 2000 - December 2002

Key Key

Inpatient admission rate per 1000 member months Inpatient admission rate per 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

• 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

• gr

am c osts of $9,012,613,680 (2.67% )

Me r

c e r e stimate s dr

• p to $147,000,000 in 2007

E

xtr apolate s e xpe r ie nc e of c hr

• nic 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

Summa ry

CCNC sho ws ho w a F

L E XI BL E struc ture b a se d o n prima ry c a re c a n re duc e c o sts a nd impro ve o utc o me s

I

t is a n e vo lutio na ry pro g ra m tie d to o ne funding struc ture -Me dic a id b ut a ffe c ts pra c tic e struc ture fo r mo re pa tie nts

Prima ry Ca re a nd He a lth Re fo rm

Prima ry Ca re the 'F

undame ntal Building Bloc k' fo r He a lth Ca re Re fo rm

I

ts ide ntity is no w c o mb ine d with the Pa tie nt Ce nte re d Prima ry Ca re ME

DICAL HOME Co nc e pt

CCNC c o nside re d na tio na l “Mo de l”

Ca ro lina Pub lic He a lth So lutio ns

T homas C. Ric ke tts, Ph.D., MPH T he Unive r sity of Nor th Car

• lina-Chape l Hill

r ic ke tts@sc hsr .unc .e du T his pr e se ntation is suppor te d by a Gillings Visiting Pr

• fe ssor

awar d at the UNC Gillings Sc hool of Global Public He alth.