1. Community Care of North Carolina 2011 Overview “Moving to Accountable Care”

2. The Goal of Reform “Triple Aim” Improving  Population Health  Experience of Care  Per Capita Cost -Berwick 2

3. “The second kick of a mule is no education!” Bill Pully NCHA 3

4. “Uniting the Tribes” McKethan  Quality tribe  Payment Reform tribe  HIT tribe  Consumerism tribe What about the provider tribes?

5. What is CCNC?  Public-private partnership that provides a framework for private health care community to manage NC Medicaid beneficiaries and now other populations  It is a state-wide network of medical homes  Result of a 10+year investment by NC  Many states are seeking help to duplicate CCNC programs and results  CCNC recognized nationally, e.g., “Innovation in American Government” award from the Kennedy School of Government at Harvard University

6. Medicaid challenges  Lowering reimbursement reduces access and increases ER usage/costs  Reducing eligibility or benefits limited by federal “maintenance of effort”; raises burden of uninsured on community and providers  The highest cost patients are also the hardest to manage (disabled, mentally ill, chronic disease etc.) the biggest need for medical homes─ CCNC has proven ability to address this challenge  Utilization control and clinical management only successful strategy to reining in costs overall

7. Key CCNC tenets  Public-private partnership  “Managed not regulated”  CCNC is a clinical partnership and collaboration, not just a financing mechanism  Community-based infrastructure, physician-led medical homes  Cut costs primarily by greater quality, efficiency

8. CCNC provides NC with:  Statewide medical home & care management system in place to address quality, utilization and cost  100 percent of all Medicaid savings remain in state  A private sector Medicaid management solution that improves access and quality of care  Medicaid savings that are achieved in partnership with – rather than in opposition to – doctors, hospitals and other providers.

9. Primary CCNC goals  Improve the care of Medicaid population while controlling costs  A “medical home” for patients, emphasizing primary care  Community networks capable of managing recipient care and enhancing the primary care system  Local systems that improve management of chronic illness in both rural and urban settings by providing additional resources (care coordinators, pharmacists etc)

10. CCNC: “How it works”  Primary care medical home available to 1.1 million individuals in all 100 counties.  Provides 4,500 local primary care physicians ( 90+% of all NC PCPs) with resources to better manage Medicaid and other populations $ 2.5-5.00 pmpm to PCP ( based on population)  Links local community providers (health systems, hospitals, health departments and other community providers) to primary care physicians ( collaboration)  Every network provides local care managers (600), pharmacists (26), psychiatrists (14) and medical directors (20) to improve local health care delivery and to assist primary care ( shared resources) $3.00-8.00 pmpm ( based on population)

11. How it works  The state identifies priorities and provides financial support through an enhanced PMPM payment to community networks and PCPs  Networks pilot potential solutions and monitor implementation (physician led)  Networks voluntarily share best practice solutions and best practices are spread to other networks- building local primary care infrastructure  The state/payers provides the networks access to data  Cost savings/ effectiveness are evaluated by the state and third-party consultants (Mercer, Treo Solutions).

12. Your Academic Partners lead the early pilots- ECU, Cabarrus FMRP, Duke, MAHEC ( Asheville)

13. CCNC networks now

14. Central Program Office (CCNC) Responsible for:  Program Development  Informatics Center ( data)  Program Evaluation  Leadership and Planning

15. Main program activities  Chronic Disease Management Initiatives (e.g. Asthma, Diabetes)  Quality Improvement Initiatives  Medical Home support  Hospital Transition Care  Emergency Department Utilization  Integration of Physical and Mental Health  Pharmacy Initiatives  Pregnancy Medical Home  IT Initiatives  Nurse and social worker care management of high-cost patients

16. Informatics Center ─ Medicaid claims data  Utilization (ED, Hospitalizations)  Providers (Primary Care, Mental Health, Specialists)  Diagnoses – Medications – Labs  Costs  Individual and Population Level Care Alerts Real-time data  Hospitalizations, ED visits, provider referrals CCNC informatics center

17.  Care Management Information System (CMIS)  Pharmacy Home  Quality Measurement and Feedback Chart Review System  Informatics Center Reports on prevalence, high-opportunity patients, ED use, performance indicators  Provider Portal CCNC informatics center

18. Summary of current CMS projects 2011 update

19. 646 Medicare demo  5 yr began Jan 2010  Quality Demonstration – must meet quality improvement target  Shared Saving model ( non –risk)  Yr 1 & 2 dually eligible Medicare and Medicaid recipients (42,000)  Yr 3-5 option to add FFS Medicare- Jan 2012 (180,000)

20. Multi-payer Advanced Primary Care Demonstration  Partnership between NC Medicaid, CMS (Medicare), BCBS and State Health Plan  3 yr demonstration beginning Oct 2011  Improve quality and lower costs in rural underserved communities  All payers provide additional support for PCPs ($2.50 pmpm) and local CCNC network ($2.50-8.00 pmpm)  Attain medical home certification, lower ED rates, avoidable admissions, E prescribing, care coordination and improved chronic disease quality metrics

21. Beacon Community  $15 million ONC grant to Southern Piedmont Community Care network  Build an all payer program to improve quality and lower costs using technology and enhanced medical home teams  3 year grant ( began April 2010)

22. 646 demo Exempt PGP demo 646 & Multi-payer Counties Camden Perquimans MartinTyrrell Hertford Dare Currituck Pasquotank Brunswick New Hanover Pender Cumberland Warren Northampton Halifax Nash Wayne Duplin Edgecombe Pitt Greene Bertie Jones Gates Carteret Pamlico Washington Hyde Chowan Robeson Columbus Bladen Sampson Person Hoke Harnett Granville Wake Johnston Vance Franklin Caswell Alamance Chatham Orange Davie Stanly Stokes Rockingham Guilford Randolph UnionAnson Richmond Gaston Mecklenburg Cabarrus Forsyth Davidson Montgomery Alleghany Wilkes Surry Ashe Catawba Yadkin Iredell Clay Polk Caldwell Watauga Mitchell CherokeeMacon Graham Swain Jackson Haywood Madison Rutherford McDowell Yancey Avery Burke Alexander Transylvania Henderson Buncombe Cleveland Lincoln Rowan Moore Scotland Lee Durham Wilson Lenoir Beaufort Craven Onslow future Beacon Advanced multi-payer primary care demo

23. Dual eligible planning grant  $1 million to CCNC and DMA to work with stakeholders in designing a comprehensive to integrate care for dually eligiables  Design improved care in facilities as well as home

24. CHIPRA Grant  Category A: Evaluate the Use of 24 new children quality measures  Category C: evaluate provider based models to improve care in children on Medicaid/SCHIP focusing on children with special health care needs ( 4 networks and 11 practices)  Category D: NC and PA working to define Children’s Electronic Health Record

25. ONC Challenge Grant  $ 1.7 million grant ( NCHIE and CCNC)  Build enhanced web based pharmacy home module  Medication reconciliation and medication management  Communication tools for pharmaicst, care managers and physiciains

26. How CCNC Works with Medicaid Medicaid Community Care CCNC Network CMC FFS payment (unchanged) + PMPM Medical Home PMPM fee ( care managers and other supports) Network rebate to support shared services Payment to support care coordinators and other supports Claims data Patient & Population data to Providers I.C.

27. How CCNC Works with BCBS ( Multi-payer demo) BCBS Community Care CCNC Network CMC FFS and contract payment (unchanged) Network PMPM Payment to support care coordinators and other supports Claims data Patient & Population data to Providers I.C. Network PMPM

28. System-wide results  CCNC in the top 10 percent in US in HEDIS for diabetes, asthma, heart disease compared to commercial managed care.  More than $700 million in state Medicaid savings since 2006.  Adjusting for severity, costs are 7 % lower than expected. Costs for non-CCNC patients are higher than expected by 15 percent in 2008 and 16 percent in 2009.  For the first three months of FY 2011, per member per month costs are running 6 percent below FY 2009 figures.  For FY 2011, Medicaid expenditures are running below forecast and below prior year (over $500 million).

30. Quality HEDIS Measures

31. Treo Solutions: analytic consultant

32. CCNC advantage  Flexible structure that invests in the community (rural and urban/academic and private)  Fully implemented in all 100 counties  All the savings are retained by the State of North Carolina  Very low administrative costs  Does not conflict with member organizations business strategy  Ability to manage the entire Medicaid population (even the most difficult) and other populations  Proven, measurable results  Team effort by NC providers that has broad support  Collaborative

33. Unique Challenge for Academic Departments under ACO framework  Academic Health Centers lack adequate primary care footprint to assume population management  Lack of experience or expertise in taking risks  Conflict between ACO success and education and research mission  Risk to institutions of rapid reduction in hospital & specialty services  Concentration on using shared savings to fill hole in bottom line rather than supporting growth of community based services

34. So could CCNC facilitate ACO development Potential Roles:  A CCNC Network as an ACO  A CCNC Network providing services to several ACOs (care management and medical home)  CCNC Informatics Center & Central Office supporting multiple overlapping specialty or IDS ACOs  CCNC providing the framework and state-wide agreement with CMS for ongoing Accountable Care development ( Medicaid and FFS Medicare) in NC 34

35. Next steps for CCNC  Build out Informatics Center and Provider Portal as a mulit-payer shared resource for all communities  Add specialists to CCNC  Develop budget and accountability model for NC Medicaid and expand 646 Medicare demo as the preferred Accountable Care structure for NC  Implement additional multi-payer projects under CCNC  Work with NCHA, IHI on best practices for reducing readmissions and other opportunities  Facilitate Accountable Care Collaborative Unite the Tribes!