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Prepared Witness Testimony The House Committee on Energy and Commerce
Evaluating Coordination of Care in Medicaid: Improving Quality and Clinical Outcomes.
Subcommittee on Health
Mr. Jeffrey Simms
Over the last ten years, the North Carolina Department of Health and Human Services through two of its agencies - the Division of Medical Assistance and the Office of Research Demonstrations and Rural Health Development, has worked diligently to link Medicaid recipients with a primary care provider in their local community, creating a medical home and addressing the access to medical services issue commonly known to Medicaid recipients. This link with the provider has established the basic infrastructure of the Community Care of North Carolina Program, also known as Carolina ACCESS I, II & III, a statewide primary care case management program. Community Care of North Carolina provides a system wherein the health care for the Medicaid population can be managed through a fee for service reimbursement environment. As of October 1, 2003 more than 700,000 Medicaid recipients across the state have medical homes with providers through this PCCM program and approximately 417,000 of these recipients are linked with one of the 2,000 providers who participate in a Community Care Provider Network that focuses on improved quality, utilization and cost effectiveness for the Medicaid program. Included in the supporting information is a map showing the distribution of the current thirteen CCNC networks across North Carolina. We are in the process of expanding the CCNC networks statewide by June 30, 2005. The Community Care of NC Program has established a structure that allows the local stakeholders in a county, which includes primary care providers, health departments, hospitals, and Departments of Social Services, to partner together and create a local health care delivery system for the Medicaid recipients receiving care in their community. The local CCNC networks identify costly Medicaid patients and services and then develop strategies that will improve utilization and cost management. This local collaboration also assists in the elimination of the fragmentation of care between public and private providers. The local Community Care Networks collaborate at the state level through the statewide clinical directors group, which selects targeted disease and care management processes that will be implemented systematically in all networks; reviews evidenced-based practice guidelines; and establishes program measures. At the present time these targeted disease and care management processes include: asthma, diabetes, pharmacy management, high risk/high cost management, and emergency room utilization. Any of the disease management initiatives implemented in Community Care of NC involves the clinical directors group setting performance standards; each network obtaining local provider buy-in; standardized physician toolkits; local and state level technical assistance; and practice level quality improvement system processes. The asthma and diabetes disease management initiatives include chart audits as a process measure whereby the state and networks can measure the providers' performance and offer feedback regarding this process measure. Since the implementation of the asthma initiative over the last four years we have seen a continual increase in the number of individuals who suffer from asthma who had documentation of staging, appropriately prescribed corticosteroids and accurate asthma action plans in the medical record. A bar graph is included in the packet showing this trend. Also included is a graph showing the chart audits for diabetes, which also shows improvements in the way providers are treating individuals who suffer from diabetes. Improvement can also be seen in the area of hospitalizations and emergency room utilization for children who suffer from asthma. For the period of April 2000 - December 2002, the rate of inpatient hospitalizations for children linked with a CCNC provider was 5.3 per 1000 member months, whereas those children linked with providers who were not participating in CCNC was 8.2 per 1000 member months. For that same period, April 2000 through December 2002, the pediatric asthma emergency room utilization rate was 158 per 1000 member months for children linked with a CCNC provider, whereas for children linked with providers who were not participating in CCNC, the rate was 242 per 1000 member months. Overall cost data shows that for calendar year 2000, the average asthma episode cost was $687 for children under 18 years of age linked with a CCNC provider and the cost for those children linked with a provider who was not participating in CCNC was $857. We are in the process of pulling more recent cost data related to the treatment of asthma. CCNC has enabled the North Carolina Medicaid program to establish medical homes for the Medicaid population across the state. However, we still struggle with the inappropriate use of the emergency room. Through the CCNC program we are able to identify patients who use the emergency room for what would be classified as routine primary care and the care managers follow up with those patients on the telephone, reminding them of their primary care provider's office hours and after hours telephone number. We are seeing the benefits of these efforts, but we are limited in the steps that can be taken to control the inappropriate use of the emergency room. During the period of July 1, 2001 through June 30, 2002, we were able to show a 6% difference in the number of children linked with a CCNC provider who received services in the emergency room when compared to the children linked with a provider who was not participating in CCNC. The CCNC infrastructure at the local level affords us the opportunity to work with the local hospitals to devise strategies to re-enforce the medical home concept and to also provide the patient's primary care providers with real time emergency room encounter sheets. We are also exploring reimbursement options for the emergency room. The physicians who participate in Community Care of North Carolina felt the need to encourage providers to take an informed look at their prescribing habits for their Medicaid patients. The providers felt the need to evaluate the relative costs of medicines prescribed in key therapeutic categories. They identified the top 100 drugs by Medicaid expenditures in North Carolina and then arranged those compounds in a tiered fashion by average wholesale price (AWP), where Tier 1 drugs offer the greatest potential cost savings to the Medicaid program. The tiered list is shared with providers throughout the CCNC network via posters, pocket-sized reference cards and an electronic drug reference entitled ePocrates. As a result of this voluntary, provider driven effort, preliminary findings show that a post-rollout period of February - March 2003 has a 22% lower expenditures compared to a pre-rollout period of September 2002 - October 2002. The actual savings equals approximately $640,000. Additionally, the CCNC infrastructure has allowed us to develop and implement a nursing home poly-pharmacy initiative that creates pharmacist and physician teams that review drug profiles and medical records for Medicaid patients in nursing homes. They determine if a drug therapy problem exists and then recommend a change and perform follow-up. Approximately, 9,208 nursing home residents had greater than 18 drugs used within a 90 day period. The criteria used to identify the individuals included: inappropriate drugs for the elderly known as "Beers drugs"; drugs used beyond usual time limit; drug use warnings and precautions; the prescription advantage list; and potential therapeutic duplication. Of the 9,208 patients, recommendations were made on 8,559 of them and 74% or 6,359 had recommendations implemented. This initiative has proven that the pharmacist and physician team approach reduces costs and improves quality. The UNC School of Pharmacy is completing the evaluation of this initiative. Potential expansion options include all nursing home and assisted living patients, including adult care home patients in North Carolina. In my conclusion the Community Care of North Carolina program provides the infrastructure for the NC Department of Health and Human Services to set priorities that can be implemented at the local level. We will continue to identify disease management initiatives and other opportunities to collaborate with public providers at the local level. We have learned that the success of this program is contingent upon community ownership, partnership, appropriately aligned incentives, behavior change, the ability to measure change and patience.
Community Care of North Carolina
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