North Carolina Seeks Expansion of Primary Care Program

North Carolina officials have asked the federal government to approve a plan to move the state's higher-cost Medicare patients into a primary care Medicaid management program that has saved the state millions of dollars during the past few years.

Officials submitted what is known as a 646 waiver to CMS earlier this year, asking the agency to approve a five-year demonstration project that would put the state's high-risk Medicare patients and dual eligibles (i.e., patients qualifying for both Medicaid and Medicare) into a primary care program known as Community Care of North Carolina, or CCNC.

Currently, CCNC provides care to more than 750,000 Medicaid recipients in the state, making the program the largest payer in North Carolina. The program relies heavily on medical homes, population health management, community-based networks and case-management services to deliver care, a combination that has produced millions in cost savings while improving quality of care, according to Allen Dobson, M.D., a family physician and assistant secretary for health policy and medical assistance at the North Carolina Department of Health and Human Services. It has thus become a "driver of quality initiatives in North Carolina," said Dobson in a recent interview with AAFP News Now.

In 2005, the North Carolina state legislature mandated CCNC coverage for 30,000 children, from birth to age 6, who were enrolled in the State Children's Health Insurance Program, or SCHIP. The legislature has since required that all of the approximately 110,000 children enrolled in the state's SCHIP receive coverage via CCNC.

"We did so well with children, the (legislature) said, 'Go handle the aged, blind and disabled,'" Dobson said. "We now have our networks managing the disabled."

With the 646 waiver, officials now are seeking to move dual eligibles and high-risk Medicare patients (i.e., patients with chronic illnesses) into CCNC in an attempt to save money and improve care for these population groups, Dobson said.

Dobson outlined the various features of CCNC and explained why the program has been so successful at saving costs and improving care during a Patient Centered Primary Care Collaborative event here on July 18. According to Dobson, between July 2002 and July 2003, the cost of the CCNC program was $8.1 million, but the program saved more than $60 million compared with what would have been spent without CCNC. The program spent $10.2 million from July 2003 to July 2004, but saved $124 million during that one-year period, said Dobson, citing an analysis conducted by Mercer Human Resources Consulting Group.

"We have had staggering results as far as the amount of savings and decreased hospitalizations," said Dobson.

In the eight years since its inception, CCNC has grown to encompass 15 networks, 3,500 primary care physicians and 1,000 medical homes. Under the program, the state pays physicians 95 percent of Medicare plus a $3 per member, per month case-management fee. The state also pays networks a $3 per member, per month fee for care and disease management.

Dobson describes CCNC as a "collaborative management system," that employs a "balanced effort around quality and cost savings." The success of the program, Dobson said, is driven by three primary factors.

The first factor is the patient-centered medical home model, which engages physicians in paying attention to details, which, in turn, pays off in improved quality. This saves the program money, said Dobson. CCNC asks patients to choose a doctor or a medical home. Physician practices have to meet certain criteria to qualify as a medical home, such as providing 24-hour access, having the ability to collaborate with other community providers and maintaining the capacity to serve as a single access point for patients, among other features. In this way, the medical home serves as the hub for patient care.

Another factor is that the community organizations collaborate, allowing the state to partner with them. "It is a clinical model, not a financial model, that makes this work," Dobson said.

The third factor is the use of case managers to help patients navigate the system and to connect the various components of the system. "We have put resources in these communities to really drive the improvement of care," Dobson said. "In other words, to connect the dots between the medical home and the hospitals and all the moving parts the patient cannot navigate."