Operating in a Statewide Accountable Care Environment from Within a Health Care System
May 15, 2011
Posted by chcablogadmin in : ACO Update
To learn more about North Carolina’s state programs in the evolving accountable care environment, as well as operating a children’s hospital as part of a large, adult-oriented health care system, we spoke with Alan Stiles, M.D., Brewer Distinguished Professor and Chair, North Carolina Children’s Hospital (part of the University of North Carolina’s UNC Health Care). Here is what we learned.
Community Care of North Carolina (CCNC) was established in July, 1998, and designed to build on the state’s existing Medicaid primary care case management program, which essentially created medical homes for Medicaid beneficiaries. The goal is to work with leadership throughout the state to improve quality and access to affordable care for North Carolinians with special attention to underserved and low income populations.
Fourteen participating networks of community physicians, hospitals and health departments, covering the entire state address overall status of enrollees by proactively managing their care through risk stratification and disease and case management, as well as providing enhanced access to care. The networks work with the state in defining, tracking and reporting performance measures that help gauge effectiveness of participating networks in achieving quality, utilization and cost objectives.
Participation is optional for the state’s approximately 1.4 million Medicaid eligibles. About 945,000 of those eligible participate in the primary care case management program. Of those, about 875,000 participate also in CCNC. CCNC’s quality/cost-saving initiatives have focused on asthma disease management, chronic care (deals with Medicare/Medicaid dual eligibles), diabetes disease management, emergency room use reduction, pharmacy (primarily focused on long term care facilities), high cost/high risk patients and heart failure. Results have been impressive — $147 million saved in fiscal year 2007 according to a William Mercer (actuarial firm) study; a 34 percent lower hospital admission rate for asthma patients under age 21; eight percent lower use of ERs by asthma patients; 24 percent lower episode costs for asthma patients; seven percent increase in referrals for diabetic eye exams, and 23 percent increase in biannual foot exams for diabetics.
Dr. Stiles credits CCNC with stabilizing Medicaid payment for care and spurring care improvement.
As the environment changed with payment reform and with the probability of ACO formation on the horizon, the Hospital has focused on cost reduction, not only in its operations, but in helping to reduce the cost of care and is doing so in concert with the other children’s programs in the state. Five percent of children on Medicaid account for 50 percent of pediatric Medicaid costs (30 percent of adults in Medicaid account for 50 percent of Medicaid adult program costs). Dr. Stiles is confident quite a lot can still be done to reduce the cost of caring for these high cost patients. He thinks costs for the high cost group of children can be reduced by 25 percent. He would partner with practices to help them change work processes and the primary care physicians’ skill set regarding care of children with chronic illness. Other issues to address are those associated with transition to adulthood as parents often stay heavily engaged with the care of these patients as the patients grow up.
Each of the N.C. program chairs was asked to look at the top 50-100 high “cost” children their institutions treated last year. A key finding was that many were “geographically challenged” (i.e., they are not near a children’s hospital and do not generally “trust” local primary care providers to care for them). This group incurred enormous emergency department costs. As a result, effort is under way to get primary care medical homes better trained and enabled to do more on their own. One area being explored is the possibility of changing payment incentives so primary care physicians can provide longer visits. The group is also exploring the use of telemedicine.
While North Carolina is well ahead of others in managing care quality and cost, and NC Children’s Hospital has been a leader in that regard, there is more yet to do. The changes on the horizon create both opportunities and challenges. Being part of a system affords certain opportunities, but it also creates complications and challenges at the same time. And there are still questions about how to best relate to primary care practices outside of the system that refer large percentages of inpatients to the Hospital for care.
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