You asked for a summary of North Carolina's Primary Care Case Management (PCCM) program for Medicaid recipients.

SUMMARY

North Carolina currently offers two primary care case management programs to Medicaid recipients: Carolina ACCESS and Community Care of North Carolina (CCNC). It began Carolina ACCESS in 1991 when it received a federal Medicaid 1915(b) waiver from the Center for Medicare and Medicaid Services (CMS) to pilot this PCCM program in five counties. (The program was implemented statewide in 2002.)

The primary goal of Carolina ACCESS was to create a “medical home” for each Medicaid enrollee with a primary care provider (PCP) who coordinates and authorizes patient care and thus reduce Medicaid expenditures by decreasing unnecessary emergency department care and duplicative services. Providers are paid based on a fee-for service model (currently 95% of Medicare fee-for service rates). Each Medicaid enrollee's PCP also receives a per member per month (pm/pm) management fee for coordinating patient care. This fee was initially $3 pm/pm and is now $1 pm/pm.

In 1998, CMS approved an amendment to North Carolina's 1915(b) waiver to implement a new enhanced Medicaid PCCM program, Community Care of North Carolina, built on Carolina ACCESS. Like Carolina ACCESS, CCNC (originally named ACCESS II/III) links Medicaid enrollees to a medical home through a PCP who provides care coordination. But, CCNC's care coordination is provided by a system of community provider networks that also offer disease and care management and quality improvement initiatives. CCNC networks are nonprofit organizations consisting of large practices and countywide partnerships involving physicians, hospitals, and health and social services departments.

Currently, CCNC operates statewide through 14 local provider networks with over 3,200 primary care providers serving approximately 838,000 Medicaid enrollees. All CCNC sites must (1) develop a risk assessment process, (2) implement a care management plan, (3) identify high cost users, (4) review emergency department utilization, and (5) implement disease management programs.

Services provided under CCNC are paid based on a fee for service model. PCPs under CCNC receive a $2.50 pm/pm case management fee (as opposed to $1 pm/pm in Carolina ACCESS). Each provider network also receives a $3.00 pm/pm case management fee to pay for care and disease management initiatives and staff.

Medicaid enrollees are assigned to Carolina ACCESS or CCNC depending on the program that their PCP participates in. The majority of the eligible Medicaid population (80%) is enrolled in CCNC. Carolina ACCESS serves approximately 14%, mostly in rural communities. Those ineligible for Carolina ACCESS or CCNC are enrolled in a Medicaid fee-for-service plan.

Two external evaluations of CCNC have demonstrated significant cost savings. The University of North Carolina's Sheps Center for Health Services Research studied CCNC's asthma and diabetes management initiatives from 2000 to 2002, estimating savings of $3.5 and $2.1 million, respectively, from each program.

In addition, the Mercer Human Resources Consulting Group conducts an ongoing actuarial analysis of CCNC's cost savings by comparing actual and projected program costs. It estimates CCNC saved approximately $60 million in FY 03, $124 million in FY 04, $81 million in FY 05, and $161 million in FY 06.

CAROLINA ACCESS

North Carolina began its Medicaid managed care program in 1986, contracting with one health maintenance organization (HMO) to provide services in three counties (Mecklenburg, Wake, and Durham). In 1996, the state contracted with five HMOs to serve Mecklenburg County and expanded the service area to four additional, rural counties. But, low Medicaid enrollment in these rural areas caused the HMOs to terminate services everywhere except Mecklenburg County. By 2002, only one HMO remained in the county; its contract ended in 2006. The state has not contracted with HMOs to provide Medicaid managed care services since that time.

North Carolina's inability to attract and maintain fully capitated managed care contracts to serve its large rural population caused the state to consider new Medicaid service delivery models. In 1991, it received a CMS Medicaid 1915(b) waiver to pilot a new PCCM program, Carolina ACCESS, in five counties. The program was created by the North Carolina Department of Human Services' Division of Medical Assistance (the state's Medicaid agency) and the Office of Research, Demonstrations, and Rural Health Development.

The primary goal of Carolina ACCESS was to create a “medical home” for each Medicaid enrollee with a primary care provider (PCP). PCPs include general practitioners, pediatricians, nurse practitioners, internists, obstetrician/gynecologists, physician assistants, federally qualified health centers, and rural health clinics. The PCP coordinates and authorizes patient care in the expectation of reducing Medicaid expenditures by decreasing unnecessary emergency department care and duplicative services. Providers are paid based on a fee-for service basis (currently 95% of Medicare fee-for service rates). Each Medicaid enrollee's PCP also receives a per member per month management fee for coordinating patient care. This fee was initially $3 pm/pm and is now $1 pm/pm.

The program was initially piloted in five counties and by 1999 was expanded to include all but one of the state's 100 counties. In 2002, Mecklenburg County became the last to implement the program in conjunction with its capitated managed care program.

According to Denise Levis Hewson, CCNC's director of quality improvement and senior consultant, while the program was successful in linking enrollees to a medical home, it did not offer enough resources and support to help PCPs provide disease management for its Medicaid population. This determination, coupled with increasing state budget constraints, caused the state to consider building an enhanced PCCM program. Levis also noted that the program's ability to reduce unnecessary emergency department care was somewhat limited after enactment of the 1997 Balanced Budget Act's “prudent layperson”

provision. This provision required coverage for emergency department services if a “prudent layperson” would have believed an emergency existed.

COMMUNITY CARE OF NORTH CAROLINA (CCNC)

In 1998, CMS approved an amendment to North Carolina's 1915(b) waiver to build upon the Carolina ACCESS program and implement a new enhanced Medicaid PCCM program, Community Care of North Carolina (originally named ACCESS II/III). Like Carolina ACCESS, CCNC links Medicaid enrollees to a medical home through a PCP who provides care coordination. But, under CCNC, care coordination is provided by a system of community provider networks that also offer disease and care management and quality improvement initiatives. CCNC networks are nonprofit organizations consisting of large practices and countywide partnerships involving physicians, hospitals, and health and social services departments.

Currently, CCNC operates statewide through 14 local provider networks with over 3,200 PCPs serving approximately 838,000 Medicaid enrollees. All CCNC sites must (1) develop a risk assessment process, (2) implement a care management plan, (3) identify high cost users, (4) review emergency department utilization, and (5) implement disease management programs.

CCNC pays providers based on a fee for service model. PCPs under CCNC receive a higher case management fee than those under the Carolina ACCESS program ($2.50 pm/pm as opposed to $1 pm/pm). Each provider network also receives a $3.00 pm/pm case management fee to pay for care and disease management initiatives and staff.

Program History

According to Levis Hewson, in 1997 the Division of Medical Assistance sent letters to Carolina ACCESS providers to determine whether they would be interested in partnering with the state to develop local, community-based provider networks that would assume additional care and disease management responsibilities in exchange for higher care management fees. After receiving a 100% favorable response rate, the state issued a request for proposals (RFP) in 1998 to identify counties interested in developing these networks. Participation was limited to communities with local provider practices already managing at least 2,000 Medicaid patients. Rural provider practices were allowed to combine their Medicaid rolls to meet this requirement.

Initially, nine projects were selected. ACCESS II comprised six networks within individual counties and one network consisting primarily of pediatricians covering 32 counties. ACCESS III consisted of two urban, countywide networks that included all of each county's Medicaid providers. According to the Division of Medical Assistance's acting managed care director, Chris Collins, the North Carolina legislature directed the state to expand ACCESS II and III statewide in 2001 at which time the program name was changed to CCNC. There is currently no distinction made between ACCESS II and III. In some rural areas, CCNC operates in conjunction with Carolina ACCESS.

Providers

To serve as a PCP in the Carolina ACCESS or CCNC programs, providers must enroll with the Division of Medical Assistance and meet certain criteria. PCPs in both programs are responsible for patient care coordination, including providing primary care services, service authorization, and referrals. Services must be accessible to Medicaid enrollees 24 hours per day, seven days per week. According to Collins, PCPs may provide after- hours call coverage directly or make arrangements with other providers or the local hospital.

In addition to these requirements, PCPs in the CCNC program must also participate in the state's disease management initiatives and network activities, follow evidenced-based practice guidelines for assessing and treating patients, and provide more intensive patient education and clinical information for data management systems.

Enrollment

North Carolina requires certain Medicaid recipients, including children; Temporary Assistance for Needy Families (TANF) families; and the aged, blind, and disabled to enroll in a Medicaid managed care plan. Enrollment for pregnant women, dually eligible (Medicare and Medicaid), and foster children is voluntary. The medically needy (generally people who do not automatically or “categorically” qualify for Medicaid but have very low incomes, few assets, and high medical bills), undocumented immigrants, and institutionalized seniors cannot participate. Medicaid enrollees do not choose between Carolina ACCESS or CCNC; they are assigned to the program in which their PCP participates. According to Levis Hewson, most Medicaid clients (80%) are enrolled in CCNC. Carolina ACCESS serves approximately 14% of Medicaid recipients, mostly in rural communities. Those ineligible for Carolina ACCESS or CCNC are enrolled in a Medicaid fee-for-service plan.

Network Staff

Each network has a clinical director responsible for implementing the network's quality improvement and disease management initiatives. The clinical director also participates in a statewide group that selects statewide initiatives, performance measures, and goals. The clinical director also leads clinicians in the network's medical management committee, which provides guidance on network activities and determines local processes for implementing statewide initiatives.

Collins noted that pharmacists recently joined each network to assist with medication management of high-cost patients. Networks also have care coordinators, generally nurses and social workers, responsible for assisting providers with (1) identifying high-risk patients, (2) disease management education, (3) care coordination, and (4) collecting process and outcome data.

Disease and Care Management Initiatives

The statewide clinical directors group develops and implements disease and care management initiatives statewide. The group initially selected three areas for such intiatives: asthma, diabetes, and congestive heart failure. The pediatric asthma program, first implemented in 1998, was found to have lowered hospital admissions by 34% and emergency room visits by 8%. And although medication costs rose (an expected result), the average episode cost for children in PCCM was 24% less than for other children. A separate study found a 37% decrease in the average monthly rates of non-urgent ER visits. Current statewide initiatives include pharmacy management, dental screening, emergency department utilization management, and care management of high-risk enrollees.

According to Collins, networks are encouraged to pilot disease management initiatives locally, which may then be implemented statewide if proven effective. On such example is CCNC's chronic care initiative. In 2005, the legislature directed CCNC to expand its services to comprehensively address the needs of its aged, blind, and disabled population. After a two-year chronic care management pilot program, the legislature recently approved permanent funding and statewide implementation. Starting October 2008, PCPs and networks take on additional responsibilities for this population; PCPs receive an additional $2.50 pm/pm (for a total of $5.00 pm/pm) and networks receive an additional $3.00 pm/pm (for a total of $6.00 pm/pm) for each such enrollee.

Program Impact

Since its inception, CCNC has been evaluated by two independent organizations. A study by the University of North Carolina's Sheps Center for Health Services Research of CCNC's asthma and diabetes management initiatives from 2000 to 2002, estimated savings of $3.5 and $2.1 million, respectively, from each program.

In addition, Mercer Human Resources Consulting Group conducts an ongoing actuarial analysis of CCNC's cost savings by comparing actual and projected program costs. It estimates CCNC saved approximately $60 million in SFY03, $124 million in SFY04, $81 million in SFY05 and $161 million in SFY06.

HYPERLINKS

Community Care of North Carolina website, http://www.communitycarenc.com/, last visited on November 6, 2008.

North Carolina Department of Health and Human Services, Division of Medical Assistance website, http://www.ncdhhs.gov/dma/mangcarewho.html, last visited on November 6, 2008.

North Carolina Office of Research, Demonstrations, and Rural Health Development website, http://www.ncruralhealth.org/, last visited on November 6, 2008.

Mercer Human Resources Consulting Group, CCNC Cost Savings: State Fiscal Year 2005 and 2006 Analysis, http://www.communitycarenc.com/PDFDocs/Mercer%20SFY05_06.pdf, last visited on November 6, 2008.

Mercer Human Resources Consulting Group, CCNC Cost Savings: State Fiscal Year 2004 Analysis, http://www.communitycarenc.com/PDFDocs/Mercer%20SFY04.pdf, last visited on November 6, 2008.

Mercer Human Resources Consulting Group, CCNC Cost Savings: State Fiscal Year 2003 Analysis, http://www.communitycarenc.com/PDFDocs/Mercer%20SFY03.pdf, last visited on November 6, 2008.

The University of North Carolina at Chapel Hill, Sheps Center for Health Services Research, Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives: January 2000-December 2002, http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf, last visited on November 6, 2008.

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