Community Care of North Carolina

It’s not quite time to publish the obituary for by far the most extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it. The HMO-friendly GOP controls the statehouse, a blistering audit on Medicaid management has just been released (with plans for a CCNC-specific audit in the works), and the state’s most influential media outlet has ”vindicated” those who were excoriated for daring to question it, such as me, to name one random person who has frankly obsessed with it.  (This might explain why I never get invited to parties.)

By way of background, the state’s Medicaid agency initiated what might loosely have been termed an enhanced-access model almost 15 years ago, and have subsequently expanded their experiment into a full-fledged patient-centered medical home, which currently covers many disabled members, the large majority of the non-disabled adults, and most of the children.

This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR. Here is the influential and literate Disease Management Care Blog on the subject:

It’s impossible it seems to read anything about the Patient Centered Medical Home (PCMH) and not run into Community Care of North Carolina (CCNC) as the ‘The PCMH Saves Money’ poster child. No power point presentation on the topic is complete without its mention, no Meeting Agenda is full if it’s not there, if you’re going to testify on the PCMH’s benefits before Congress, you should bring it up , the Commonwealth Fund is working hard to replicate it and it’s even embedded in Medical Home Wikipedia.

Further, North Carolina and states that wanted to adopt this model were given an unprecedented 9-to-1 federal match, reflecting the Obama Administration’s admiration for its success.

Continue reading “Community Care of North Carolina’s Last Chance: To Fool the Legislature Rather than Answer the Questions”

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The ongoing saga of savings estimates for the Community Care of North Carolina (CCNC) patient-centered medical home (PCMH) is finally over.  The verdict: no savings. Because the scale and visibility of the CCNC experiment are unparalleled in the Medicaid sector today, it is important that the right policy and delivery system lessons be learned from this dispositive conclusion.

Lesson 1:  Enhancements in access do not necessarily create cost reductions, at least in Medicaid.

CCNC is by all accounts an excellent program from the patient’s perspective.  Indeed, if I were a Medicaid recipient, I would want to live in North Carolina.  The leadership of CCNC is passionate about the program and constantly strives to improve it.  However, as was amply observed by J.D. Kleinke on this very blog last week, Medicaid recipients have many lifestyle and economic issues that even the best-intentioned and best-incentivized doctors will never be able to systematically address.

Lesson 2:  Perhaps it is time to create an ER co-pay for Medicaid recipients that has more than one digit to the left of the decimal point.

Even as ER co-pays for commercial insurers have soared in the last decade, Medicaid ER co-pays remain virtually non-existent.  CCNC created excellent reasons to use primary care but was not permitted to re-price the ER to economically encourage use of primary care.  Many Medicaid recipients overuse the ER in part because it is basically free.  For the CCNC experiment to truly have a chance to reduce ER visits now that they have created a worthy substitute with their PCMH, it’s only fair to them (and to taxpayers) to reconfigure the financial incentives so that people use their worthy substitute … and then re-measure savings.

Continue reading “North Carolina Medicaid’s Patient-Centered Medical Home: Lessons Learned”

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