Oct. 12--Medicaid, the system for providing medical care to poor people, seems afflicted by an illness itself. It bleeds money.
But in North Carolina, a novel approach called Community Care may have found a cure. One way Community Care saves money is by keeping up with Medicaid patients who have chronic diseases such as diabetes and asthma. By making sure patients are receiving medicines and other treatment, the program cuts down on costly emergency room visits and unnecessary hospital stays.
An independent analysis shows that the state saved $2 for every dollar it spent on the Community Care system, which treats more than 810,000 Medicaid patients in 14 nonprofit networks around the state. That translates to $100 million a year in savings.
Now the success of Community Care of North Carolina is drawing national attention. The principles that guide it -- monitoring patients closely and emphasizing disease prevention -- could become the foundation for national reforms of Medicaid -- and also Medicare, the program for people 65 and older.
At a forum in Washington on Friday, representatives of the major-party presidential campaigns are booked to discuss the role the North Carolina medical-home model can play in health care reforms. In the medical-home model, patients are assigned to a case manager who helps them navigate the health care system.
"North Carolina has led on this -- it's had an instrumental role," said Dr. Ted Epperly, president of the American Academy of Family Physicians and moderator of this week's forum.
As Medicaid and Medicare costs spike -- last year's tab topped $500 billion nationally -- representatives from Community Care of North Carolina have answered requests from 32 other states to talk about the system.
Paul Harrison, executive director of Community Care of Wake and Johnston Counties, one of the system's networks, said he gets constant requests for information.
"We have people flying out to Maine and Connecticut to speak about this program in the next few weeks -- and that's just us," Harrison said.
A quiet success
Supporters call Community Care of North Carolina a quiet success that has gained attention across the political spectrum during its decade of existence. U.S. Sen. Richard Burr joined Sen. Dick Durbin, an Illinois Democrat, in sponsoring medical-home legislation in the Congress last year.
"He thinks it's worked well in North Carolina and that it's an excellent piece of an overall health care plan," Burr spokesman Chris Walker said Friday. "He's hoping to encourage other states to adopt something like this."
And Lt. Gov. Beverly Perdue, a Democrat running for governor, said Wednesday the medical-home model is "the most magnificent thing happening in America."
The medical-home system, also called "patient-centered care," gives patients a case manager. The manager works with doctors, other professionals, public health agencies, public hospitals, social service agencies and community health centers to take on all the patients' health care needs. Doctors get help with time-consuming, uncompensated general care and a management fee to subsidize extra costs.
Case managers often arrange transportation, follow up with patients who visited an emergency room for non-emergency care, send reminders about flu shots and checkups, and provide referrals to social service or public health department programs. For patients, the system smooths over or bridges many of the obstacles to getting seamless care.
North Carolina Medicaid administrators, notably former director Dr. Allen Dobson, developed the program in the late 1990s through an agreement between Medicaid and the state office Office of Rural Health and Community Care. The current economic crisis puts a premium on its efficiency in health care, said Tom Vitaglione, senior fellow for health and safety at Action for Children North Carolina.
"A medical home, as far as we know at this point, is the most efficient way of delivering care," Vitaglione said.
Medical-home model
Patricia Newton, 43, of Goldsboro learned about the medical-home model through Goldsboro Pediatrics when her children, Antwon and Ebonni, were enrolled in Community Care.
"It was always so great," Newton said. "The only thing I have is praise."
Antwon, now 21, had problems with asthma. Ebonni, 23, had diabetes, high blood pressure and kidney problems -- the kinds of chronic disease the system is designed to manage. Both got referrals to appropriate specialists as well as thorough ongoing care, she said.
"Antwon came home one time and said, 'Mama, I keep seeing numbers in the air on people's faces,' " Newton said. "I didn't know if it was a neurological thing, or what was wrong."
A case manager sent Antwon to a neurologist who diagnosed a form of seizure and treated it.
"They have a such a passion for what they do, that you love them business-wise," Newton said.
In addition to coordinating care, the networks tackle a looming problem: Primary care physicians, such as family doctors and geriatricians, don't earn enough to attract new generations of medical students into such practices.
Physicians in charge
"What's different about this is that the doctors, the pediatricians, the family physicians are really in charge," said Adam Searing, director of the N.C. Justice Center's Health Access Coalition. "Health providers are getting reimbursed for the time they take in providing the care. If the doctor gets some monthly amount, and you have enough patients, that adds up to another person in your office that can handle [case management]."
Liberal-leaning nonprofits such as the Justice Center support the medical-home model. However, the nonpartisan, nonprofit Patient Centered Primary Care Collaborative, sponsor of Friday's forum in Washington, also includes corporations such as Caterpillar, General Motors and IBM.
Private insurers are also showing keen interest in the medical-home approach, setting up test programs to assess long-term savings and quality improvement, said Rohan Beesla, policy director for the Patient Centered Primary Care Collaborative.
And Medicare, the federal health insurance plan for people 65 and over, will have pilot projects using the approach early next year.
In North Carolina, a group set up to pursue new affiliations for the state's networks is talking with the federal Centers for Medicare and Medicaid Services about adding Medicare patients to its plan in 2009, said Dr. Steven E. Wegner, president of the coalition, called the N.C. Community Care Network.
"It would be a different use of Medicare funds," Wegner said. "It has to be approved, and it has to be budget-neutral -- we would be responsible for any overruns. There is an upside so that if we save money and improve quality, we will share some of the savings with the federal government."
For some, the medical-home approach may sound uncomfortably close to managed-care programs offered by commercial insurers, which can closely limit benefits. Proponents say the North Carolina system differs in offering a gateway instead of a gatekeeper.
"Managed care usually means that there are restrictions on care, that there is a fiscal aspect to decision making," said Vitaglione. "What we are talking about here is really a care-based model. There are incentives given to providers to keep families under continuous preventive care."
thomas.goldsmith@newsobserver.com or 919-829-8929
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