North Carolina Medicaid switches to "opt out" for its duals

In the past, North Carolina's dual-eligibles were unable to participate in the state's care coordination network, unless they opted in. An individual had to request to be assigned to a medical home, in which case they would receive enhanced services, such as disease management.

First, an aged, blind, and disabled (ABD) initiative was started statewide in October 2008, which enhanced services available to participants.

"Our Community Care of North Carolina (CCNC) Networks developed a hospital transition program that includes pharmacists providing medication reconciliation," says Chris Collins, deputy director of North Carolina's Office of Rural Health and Community Care and assistant director of the Division of Medical Assistance–Managed Care.

"Most of our networks receive real-time data from the hospitals," says Ms. Collins. "The networks care manager is often able to initiate contact with recipient inpatient, and, together with the hospital, begins the process of transitioning the recipient back to the primary care provider."

Key components of the process include reconciling the medications between claims, the primary care record, hospital record, and medications in the home environment, and ensuring that the recipient is re-linked quickly with the primary care provider post-discharge.

Switch to "opt out"

The ABD population is comprised of two eligibility types, one that has only Medicaid and one that is dually eligible, having both Medicare and Medicaid. North Carolina's managed care is a primary care case management (PCCM) model, not a managed care organization (MCO) model.

However, this doesn't change the Centers for Medicare & Medicaid Services' guidance that prohibits a state from mandating that a dual- eligible recipient participate in a managed care program. For this reason, individuals had to opt in in order to receive the services of the network.

To increase participation, the state plan amendment was just changed to move to an "opt out" system. "Individuals are now being enrolled in the PCCM model, but may request to opt out of the program," says Ms. Collins. "We want to be able to offer the same level of medical home and network services such as care management, disease management, transition care, and pharmacy services to our high-risk, dually eligible recipients."

In order to be considered as a medical home, a provider must sign a Carolina Access agreement with the division of medical assistance. A Carolina Access provider who wishes to join his or her local CCNC network will enter into a separate contract with the regional network that includes additional requirements, such as being audited for quality measures.

"However, if an individual has been seeing a family doctor for years and is suddenly assigned to another primary care provider who participates in managed care, that person would logically opt out to maintain the relationship they have with their doctor," says Ms. Collins.

For this reason, the initial strategy is to bring in individuals who already have relationships with one of the participating providers. At the same time, managed care consultants are actively recruiting new primary care providers into the Carolina Access program. "Over the past year, they have enrolled over 120 new primary care practices," says Ms. Collins.

Data gaps are challenging

"One of the strengths of the North Carolina system is that we have the vast majority of claims data in a single system that is available to the networks and the primary care providers through an informatic center that the networks have developed," says Ms. Collins.

In spite of this robust data set for the dually eligible, Medicaid is missing key claims. Prescription drugs are purchased through multiple Medicare Part D plans, and, as such, are not captured in payment systems. "This is highly important data for this population and limits our pharmacy efforts to medical records and home visits," says Ms. Collins. "Claims can be a highly effective way to identify some medication errors and create care alerts."

As Medicare is the primary payer, providers may elect not to file for Medicaid's secondary payment. This is particularly likely if no or minimal payment is owed. "States have been offered the opportunity to secure Medicare data, but there is a cost associated with retrieval, integration, and storage," says Ms. Collins.

Prevent readmission

Preventing hospital readmissions is a primary goal of the new ABD initiative. The emphasis is on transitional care and medication reconciliation.

"We reviewed the literature on readmissions. We found that for the population that goes in and out of the hospital, it often happens because there's no intervention post-discharge," says Ms. Collins.

For example, a discharged patient may fail to see his or her primary care physician within 30 days. While primary care physicians used to routinely see their patients who were admitted to the hospital, this is no longer the case.

"Hospitals have internists, and so it is not uncommon that when the patient is admitted, the primary care physician isn't even notified," says Ms. Collins. "That patient can be discharged on a new set of medications that the primary care physician isn't aware of. That is the piece our care coordination team is closing the loop on."

In some cases, the primary care physician is provided with a list of medications for Medicaid recipients. "But for the duals, the list is missing the claims details," says Ms. Collins. "We can't say, 'Here is the fill history for this person.' But at least through our transition program, we know what has been prescribed by the primary care provider, the hospital, and what medications are in the home. Then we can close the loop with the primary care physician and provide significantly more information."

Care managers are part of the clinical team and often have space right in the primary care offices. They generally have access to the medical record, so they can see what the primary care provider has prescribed. "Increasingly, they have access to the hospital record," says Ms. Collins. "All these tools assist the pharmacist with medication reconciliations and provide the primary care provider with clinically relevant recommendations."

Recently, a state law was modified to allow mental health information, such as psychiatric medications, to be exchanged with the patient's primary care physician. "This has further assisted us in making sure that patient's medications are not [contraindicated]," says Ms. Collins.

Stronger relationships

The ABD population has higher rates of comorbid conditions, and often has multiple disease states. "So, they're different than the population in our disease management programs. We have found they frequently have overlap with mental health and substance use," says Ms. Collins.

To address these unique needs of the ABD population, stronger relationships were needed between the care coordination networks and Local Management Entities (LMEs). LMEs work with local mental health providers to move services to out-of-state facilities and strengthen the mental health services available in the communities.

"We are partnering with our LMEs on this," says Ms. Collins. "For example, if this patient is admitted for psychosis, how can we bring our systems together to do the transition? The goal is to bring the CCNC and LME networks closer together for joint planning, so that the whole person's needs are addressed."

Similarly, the LMEs are closely tied to the state mental health facilities. If a patient has just been discharged with uncontrolled diabetes, the two entities work together to be sure their medical needs are met.

Readmission rates are expected to decrease as a result of these activities. However, fiscal constraints mean there is a need to focus on immediate cost savings as opposed to long-term quality improvement gains.

"The infrastructure was built for the long haul, and we've [had] cost savings that resulted from the higher quality of care," says Ms. Collins. "But that is very different from the current budget crisis, which is forcing the division of medical assistance to look for immediate cost savings opportunities."

During the last round of budget cuts, provider rates were cut, but E/M codes that primary care providers use were protected. "We tried to protect our medical homes, which was a very positive message to our primary care providers," says Ms. Collins. "Our state has a long history of promoting medical homes, as well as patients having strong relationships and access to primary care providers."

Finally, the CCNC Networks have entered into a direct contract with CMS for a 646 demonstration. This will initially manage the care of 30,000 dually eligible beneficiaries receiving care in 150 practices in 26 counties.

"If a readmission or a hospitalization for the duals is prevented, those savings go to Medicare," says Ms. Collins. "And if we are transitioning folks back into the community and preventing a nursing home admission, then Medicaid is the beneficiary of that. So, with good care of duals, both sides benefit."

Contact Ms. Collins at (919) 855-4780 or