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