medicaid transformation - nchica · • improve health care quality, enhance patient safety,...
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Medicaid Transformation
1. NC Medicaid is moving to managed care.
2. A key policy goal is helping providers transition.
3. A second key goal is building on existing infrastructure
at the community level.
4. The Advanced Medical Home (AMH) model is one key
part of the strategy.
Advanced Medical Home
• The Advanced Medical Home program will:
– Build on NC’s strong foundation of primary care
infrastructure and capabilities as NC transitions to managed
care
– Increase medical home capabilities and performance
expectations in partnership with providers and PHPs.
• Care management will be a shared responsibility of
providers and PHPs.
• Special effort will be made to mitigate providers’
administrative burdens in the transition.
Advanced Medical Home
Tier
Base
Payment
Structure
Primary responsibility for care
management
Minimum
Medical Home
Payment (PMPM)
Care Management FeeOutcome-based
Payment ($)
1-1 FFS*
PHPs, but with requirements to
coordinate with practices and
perform locally/regionally
Legacy Carolina
Access I & IINone Optional**
3-4 FFS*
Practices and/or their
delegated “Clinically
Integrated Networks” (CINs)
Legacy Carolina
Access II levels
Negotiated between
AMH/CIN and PHPRequired
Data Support for the Advanced Medical Home
Types of information AMHs will need:1. Files identifying attributed beneficiaries
2. Results of risk stratification for attributed beneficiaries
3. Beneficiary-level screening data collected by PHPs
4. Interim (and actionable) quality measure performance information
5. Beneficiary-level claims data to delegated CIN (Tier 3+ AMHs)
6. Admissions, Discharge, Transfer (ADT) information
7. Select clinical information from electronic health records
8. Immunizations and gap notification
Data Support for the Advanced Medical Home
Summary Points
1. NC HealthConnex will be a key source of data for population-
accountable providers.
2. NC HealthConnex will be both a “noun” and a “verb” (i.e., a
destination and a data source).
3. Both the noun and verb will be implemented in a focused way.
4. NC HealthConnex will support different configurations of
standalone providers, CINs, health plans, and consumers.
NORTH CAROLINA HEALTH
INFORMATION EXCHANGE AUTHORITY
Department of Information TechnologyJason W. BucknerAssistant Director
We connect health care providers to safely and securely share health information through a trusted
network to improve health care quality and outcomes for North Carolinians.
S T A T E D E S I G N A T E D
North Carolina’s state-designated health
information exchange
S E C U R E
Secure statewide network for
physicians and other health
care providers in North
Carolina to share important
patient health information to
improve patient care
P A R T N E R S H I P
Housed within the Department
of Information Technology’s Government Data Analytics
Center (GDAC). Our
technology partner is SAS
Institute.
The Vision for Connectivity North Carolina set out a vision to create communities of connected health care providers electronically across the state.
• Allow providers to view their patients’ longitudinal health record in real-time
• Improve health care quality, enhance patient safety, improve health outcomes
• Consolidate data reporting requirements across the state to ease administrative burden and create efficiencies by eliminating duplicative data integrations
• Create outbound services to give providers insight to their at risk patient population
What Does the Law Mandate?Hospitals as defined by G.S. 131E-176(3), doctors (licensed to practice under Article 1 of Chapter 90 of the General Statutes), and mid-level practitioners who provide Medicaid services and who have an electronic health record were required to connect by June 1, 2018.
All other providers of Medicaid and state-funded services shall connect by June 1, 2019 except:
• Dentists and ambulatory surgical centers are required to submit clinical and demographic data by June 1, 2021
• Pharmacies are required to submit claims data pertaining to State services once per day by June 1, 2021, using pharmacy industry standardized formats
Connection Metrics – June 2018 DeadlineData through July 2018
UNIQUE PROVIDERS
# Medicaid Providers classified as a NP, PA, or attributed to a Hospital
37,604
PERCENT CURRENTLY CONNECTED/LIVE TO NC HEALTHCONNEX
78%% Medicaid Providers classified as a NP, PA, or attributed to a Hospital
Significant Progress
Number of Connected Facilities
Spring 2016 Spring 2017 Summer 2018
108 Facilities 877 Facilities 3,800+ Facilities
Number of Facilities in the Onboarding Process
2016 2017 2018
158 Facilities 578 Facilities 3,500+ Facilities
13
35M Total CCDs & 447M Total HL7 messages exchanged since March 1, 2016
Messages Exchanged
0
50,000,000
Apr 18 May 18 Jun 18 Jul 18 Aug 18
HL7 Messages per Month
ADT ORU Medication
0
5,000,000
10,000,000
Apr May Jun Jul Aug
Total CCDs per Month
2017 2018
Patient ID Name Date of BirthAddress/
PhoneLanguage
Race/ Ethnicity
Gender
Date of Visit Visit Number Reason for Visit Level of Care Visit LocationCare Team Members
Vital signs (height, weight, BP, BMI)
Immunization ReferralsCare plan field(s),
including goals and instructions
ProblemsMedication
Allergies
Medications Laboratory Test(s)Laboratory
Value(s)/Result(s)Smoking Status
DischargeSummary
Procedures
What Data Elements Do We Receive?The NC HealthConnex Data Target
We aim to collect all Meaningful Use Data Elements
Charting the Course ….
Foundation
ExchangeServices
PopHealth & Analytics
Notifications
AMH Data Strategy – Foundational Focus
Foundation
ExchangeServices
PopHealth & Analytics
Notifications
Trust Framework• Participant Agreement
• Governance Model
Identity Management• Master Person & Organization Index
• Robust Attribution Methodologies
Data Management• Data Quality Program & Tools
• Robust Analytical Toolset
Infrastructure• Connectivity
• Scalability
AMH Data Strategy – Exchange Services
Access a Patient’s Clinical Record• Clinical Portal
• EHR Integration
Communicate PHI Securely• DIRECT Secure Messaging
Connect to State Repositories• Controlled Substance Reporting System (CSRS)
• NC Immunization Registry (NCIR)
• Electronic Lab Reporting (hospitals only)
Exchange Services
Foundation
PopHealth & Analytics
Notifications
AMH Data Strategy – Notifications
Proactively Monitor Patient Activity• Provider/Payer defined attribution drive
notifications of ED, Inpatient, Ambulatory
encounters
• Enhanced Clinical Intelligence Engine notification• Immunization Gap
• Critical HbA1c lab value for diabetic
• High risk patient with controlled substance fillNotifications
Foundation
Exchange Services
PopHealth& Analytics
Step 1Participant Submits Patient File for NC HealthConnex to
Monitor
Step 2NC HealthConnex
monitors the network for qualifying events
Step 3Participant Receives
Notification File
AMH Data Strategy – PopHealth & Analytics
Classify & Measure Your Patient Population
• Registries
• Diabetes Registry
• Future Possibilities: Stroke, Asthma
• Measurement
• Heart Health Now Cardiac Measures
• Future Possibilities: eCQM
PopHealth& Analytics
Foundation
Exchange Services
Notifications
AMH Data Strategy – NC HealthConnex Summary
1. Strong foundation to ensure high quality, highly
available services to providers, plans, clinically
integrated networks, etc.
2. Exchange of clinical data for view or
consumption into electronic system
3. Single access point for multiple state repositories
4. Proactively monitor all events or targeted events
with NC*Notify
5. Classify & measure populations
Foundation
ExchangeServices
Pop Health & Analytics
Notifications