The Factors Shaping NC Health Choice and its Relationship with Community Care of North Carolina
Creators: name: Schaaf, Emily Vander
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2010

description: American policy governing children's health services changed in 1997 with the passage of legislation mandating that each state create a government-run health insurance program aimed at providing health care coverage for children of families earning too much to qualify for Medicaid and not enough to be able to independently purchase private insurance. (Lambrew 2007) States were afforded flexibility to develop a program that fit these simple criteria and some federal funding would be provided to states based on an algorithm using the state's number of uninsured children and average state income level (Gitterman et al. 2007). Out of a broad constellation of political and contextual variables, North Carolina developed and implemented NC Health Choice (NCHC) in 1998. This was a separate block-grant program; the state was not mandated to enroll eligible children if sufficient funding was not available. It would serve children from birth to age 18 in families earning between 100 and 200% of the federal poverty limit (FPL). It was also to be administered by the State Health Plan (SHP) and paid by a third-party payer, Blue Cross Blue Shield of North Carolina (BCBSNC). Over the subsequent decade, NCHC changed in response to internal or external pressures (Gitterman et al. 2007). Community Care of North Carolina (CCNC) is a care management program first piloted in 1988 and implemented statewide on North Carolina Medicaid patients in 2006. The program is divided into fourteen networks across the state, each striving to maximize health benefits and reduce costs. These networks utilize care managers to promote appropriate health behaviors amongst individual higher-risk or chronic patients. Care managers are intended to ensure that their patients understand treatment regimens as well as appropriate utilization of specialist and emergency room care. The networks also fuel population-based efforts to reduce overall spending, such as requiring prior authorization for prescribing brand name medications over generic ones. In compensation for this added effort, and to reward providers for creating healthier patients, physicians and networks are given a per-member-per month(PMPM) fee.(CCNC Website; Steiner et al. 2008, 361; Willson 2005, 229-233). Studies have shown CCNC to be highly effective at improving health outcomes while reducing state cost. CCNC reports a 21% increase in the numbers of asthmatic patients who have been staged and a 112% increase in asthmatics receiving the flu vaccine. In addition, asthmatics enrolled in CCNC had an average of 34% fewer hospital admissions and 8% fewer emergency department visits than did controls. The Mercer Human Resources Counseling Group projected that CCNC's strategies would produce savings of $60 million dollars in 2003, $124 million in 2004, and $231 in 2005 and 2006.(CCNC Website) As a result, North Carolina's unique solution to creating Medicaid medical homes has been widely touted as a success both locally and nationally. With such an obviously successful structure for managing and improving care in place, would it not be reasonable to expect that state policymakers would extend CCNC 's portfolio to include NCHC children as well? In 2007, the General Assembly enacted the necessary enabling legislation to make CCNC responsible for managing the care of NCHC recipients. Beginning in March of 2007, NCHC was still administered by SHP and paid for by BCBSNC, but care managers and CCNC networks were to manage the patients' health. In July of 2009, however, the General Assembly reversed course, removing NCHC recipients from CCNC management.(Gitterman et al. 2007; Sack 2009, 1) This study examines the political and circumstantial factors that contributed to the development of the initial NCHC program and shaped its subsequent triumphs and troubles. It also examines the role of these and other factors in the relationship between NCHC and CCNC, including what may have led to the decision to include- and later remove- NCHC under CCNC care management.