NORTH CAROLINA OBSTETRICAL AND GYNECOLOGICAL SOCIETY &

THE NORTH CAROLINA SECTION OF ACOG

Friday, April 8 Presentations

This activity is jointly provided by the American College of Obstetricians and Gynecologists.

3/21/2016

1

Making healthcare remarkable

Stay Ahead:Avoiding the Complications of Obstetrical Hemorrhage

John R. Allbert, MD

Maternal Fetal Medicine Associates

Obstetrical HemorrhageGoals and Objectives

Be able to identify high risk patients obstetrical hemorrhage

Know how to assess the severity of the hemorrhage

Understand the key components of a hemorrhage protocol

Case Presentation

18 y/o G-1 P-0 at 22 weeks

IUFD with complete abruption

Large intrauterine hematoma

BP 82/20, P-128

Urine output <10cc past 4 hours

Cervix long, thick and closed

Severe Obstetrical HemorrhageEBL > 1000 ml

Postpartum hemorrhage 1-5% of deliveries, 15% will be severe

Risk of death 1/100,000 in developed countries and 1/1000 in undeveloped countries

Most common reason postpartum patients are admitted to the ICU

Hemorrhagic shock can lead to Sheehan’s Syndrome, occult myocardial ischemia or death

Maternal Mortality and Severe Morbidity

Cause Mortality(1-2 per 10,000)

ICU Admit(1-2 per 1000)

Severe Morbidity(1-2 per 100)

VTE and AFE 15% 5% 2%

Infection 10% 5% 5%

Hemorrhage 15% 30% 45%

Preeclampsia 15% 30% 30%

Cardiac Disease 25% 20% 10%

North Carolina: Mortality Mostly Preventable

Cause of Death (n=108) % of All Deaths % Preventable

Cardiomyopathy 21% 22%

Hemorrhage 14 93PIH 10 60

CVA 9 60

Chronic condition 9 89

AFE 7 0

Infection 7 43

Pulmonary embolism 6 17

Berg CJ, Harper MA, Obstet Gynecol. 2005;106:1228

3/21/2016

2

POSTPARTUM HEMORRHAGEPlacenta Percreta

12 Week Uteroisthmic Pregnancy

12 Week Uteroisthmic Pregnancy MRI Hepatic Rupture

Abruption

PIH/HELLP

Amniotic fluid embolus

Acute fatty liver

Accreta

Uterine scar pregnancy

PregnancyLife Threatening Hemorrhage

Uterine infection

Uterine rupture

Hydatiform mole

Retained IUFD

Uterine inversion

Lacerations

Council on Patient Safety in Women’s Healthcare

Partnership for Maternal Safety3 Maternal Safety Bundles in July 2013

Postpartum Hemorrhage

Severe Hypertension in Pregnancy

Venous Thromboembolism Prevention

3/21/2016

3

So What is a Bundle? So what’s a bundle?

Not a guideline

Selection of existing guidelines and recommendations in a form that aids implementation and consistency of practice

All elements necessary AND sufficient

All or nothing measurement, you either did it or you didn’t

Main EK, Obstet Gynecol 2015;126:155

Bundle Examples

Central Lines

using proper hygiene and sterile contact barriers; properly cleaning the patient’s skin; finding the best vein possible for the IV; checking every day for infection; and removing or changing the line only when needed.

Ventilator-associated Pneumonia

raising the head of the patient’s bed between 30 and 40 degrees; giving the patient medication to prevent stomach ulcers; preventing blood clots when patients are inactive; and seeing if patients can breathe on their own without a ventilator

Involvement Was Diverse

American Association of Blood Banks

American Academy of Family Physicians

American College of Nurse-Midwives

ACOG

AWHONN

SMFM

Society of Obstetric Anesthesia and Perinatology

Obstetric Hemorrhage BundleEndorsed by the Council July 2014

Improve Readiness to hemorrhage by identifying standardized protocols (general and massive)

Improve Recognition of OB hemorrhage by performing on-going objective quantification of actual blood loss

Improve Response to hemorrhage by utilizing unit-standard, stage-based, hemorrhage emergency management plans with checklists

Improve Reporting/Systems Learning of OB hemorrhage by performing regular on-site multi-professional hemorrhage drills

Obstetric Hemorrhage BundleFour Action Domains

Readiness

Recognition and Prevention

Response

Reporting/Systems Learning

3/21/2016

4

Readiness

Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compression stitches

Immediate access to hemorrhage medications

Establish a response team: who to call when help is needed, (blood bank, anesthesia, pharmacy, advance gynecologic surgery, social services, chaplain)

Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)

Unit education on protocols, unit-based drill debriefs

Hemorrhage MedicationsStorage

Obstetric HemorrhageMedication Kit

[ ] Oxytocin (Pitocin) 20 units/liter 1 bag [ ] Oxytocin (Pitocin) 10 units 2 vials [ ] 15-methyl PGF2α (Hemabate) 250 micrograms/milliliters 1 ampule * [ ] Misoprostol (Cytotec) 200 microgram tablets 5 tabs [ ] Methylergonovine (Methergine) 0.2 milligrams/milliliters 1 ampule * * Needs Refrigeration

Postpartum Hemorrhage Kit

Obstetric HemorrhageHemorrhage Cart

Vaginal[ ] Vaginal retractors; long weighted speculum

[ ] Long instruments (needle holder, scissors, Kelly clamps, sponge forceps)

[ ] Intrauterine balloon

[ ] Banjo curette

[ ] Bright task light

[ ] Procedural instructions

Cesarean/Laparotomy

[ ] Hysterectomy tray

[ ] #1 chromic or plain catgut suture & reloadable straight needle for B-Lynch sutures

[ ] Intrauterine balloon

[ ] Procedural instructions (balloon, B-Lynch, arterial ligations)

Postpartum Hemorrhage Kit

3/21/2016

5

4 Domains of Patient Safety Bundles

Readiness

Recognition and Prevention

Response

Reporting/Systems Learning

Obstetric HemorrhageRecognition/PreventionEvery Patient

Assessment of hemorrhage risk

Measurement of cumulative blood loss

Universal active management of 3rd stage of labor

Assessment of Hemorrhage RiskPrevention

Helps improve readiness

Early recognition

Increase use of preventive measures

Prepare for early aggressive response to bleeding

Assessment of Hemorrhage Risk

Identifies 25% of patients as high risk

Identifies 60% of patients with severe hemorrhages

Thus 40% of hemorrhages occur in low risk patients

Dilla AJ, Obstet Gynecol 2013;122:120

Admission Risk Assessment & Testing

Low Medium(Type and Screen)

High(Type & Crossmatch)

No known bleeding disorder

Prior C/S or uterine surgery Placenta previa, low lying placenta

≤ 4 previous vaginal births Multiple gestation Suspected accreta

>4 previous vaginal births Hct <30 AND other risk factors

Chorioamnionitis Platelets <70,000-100,000

Previous PPH Known coagulopathy

Large uterine fibroids Active bleeding

Assessment of Hemorrhage RiskPrevention: Assess Risk

Antepartum

Admission to LDR

During labor

Transfer to postpartum care

3/21/2016

6

Obstetric HemorrhagePlacenta Accreta Management

For one or more prior C/S, placenta location must be documented prior to scheduling delivery

Patients at high risk of accreta should:

-Obtain proper imaging

-Be transferred to appropriate level of

care for delivery if accreta is suspected

PLACENTA PERCRETAUltrasound Diagnosis

Accreta at 11 weeks Accreta

Hemorrhage Risk AssessmentPrevention

May indicate need for T&S or T&C

Confirm availability of blood replacement products

Assess need to transfer or confirm availability of surgical or radiologic expertise

Create multidisciplinary plan for women who refuse blood products

4 Domains of Patient Safety Bundles

Readiness

Recognition and Prevention

Response

Reporting/Systems Learning

3/21/2016

7

Obstetric HemorrhageAssessing the Degree of Hemorrhage

Volume of blood already lost (estimated blood loss) Rate of bleeding (at the time of evaluation) Consequences of blood loss: Hemodynamic abnormalities (blood pressure, pulse, urinary output) Hemoglobin/Hematocrit abnormalities Metabolic abnormalities (pH, base deficit, lactic acid) Coagulation abnormalities (PT, PTT, INR, fibrinogen, platelets) Patient’s clinical status (anxious, confused, lethargic)

Postpartum HemorrhageQuantitative Blood Loss QBL

• Perform for every birth and begin immediately after infant delivery and continue until bleeding is stable, (2-4 hrs)

• Visual estimation can underestimate by 33-50%

• QBL reduces the likelihood that clinicians will underestimate the EBL and delay treatment

• “She’s bleeding a lot” vs. “She has a 1200 ml QBL”

Patel,A International J of Gynecol Obstets 2006;93:230

Postpartum HemorrhageQBL• Weight: Total weight of

blood saturated items (laps, chux, cloth pads) –their dry weight. One gram = One milliliter

Direct Measurements: graduated suction canisters, Under-buttocks and OR drapes with calibrated pouches

Postpartum HemorrhagePreventionActive Management of the 3rd Stage of Labor

• Oxytocin 10 unit bolus

• Controlled cord traction, (Brandt maneuver)

• Uterine massage after delivery of the placenta

4 Domains of Patient Safety Bundles

Readiness

Recognition and Prevention

Response

Reporting/Systems Learning

Hemorrhage: How Much is too Much

500 mL for vaginal and >750 mL for C/S

WHO: EBL >500 mL an “alert line” and >1000 mL an “action line”

ACOG (reVITALize): EBL >1000 mL for either vaginal or C/S with enhanced surveillance and early interventions, as needed, for 500-1000 mL

4-5% of women >1000 mL- A clinically significant amount

3/21/2016

8

Determine the Exact Etiology: The 4Ts

Tone: 70%, Atonic uterus

Trauma: 20%, Lacerations, inversion, rupture, hematomas

Tissue: 10%, Retained tissue, accreta

Thrombin: 1%, coagulopathies

Triggering: Vital Signs and EBL

70ml/kg (5L)

6-7L in late pregnancy

HemorrhageClassification by Volume

% Blood Volume Volumes (ml)

Class I 15% 900

Class II 20-25% 1200-1500

Class III 30-35% 1800-2100

Class IV 40% 2400

HemorrhageClass I Hemorrhage (900ml)

Tachycardia < 100

Pulse pressure <30 mmHg

SBP 80-100 mmHg

Mild hypotension

Palpitations

Dizziness

HemorrhageClass II Hemorrhage (1200-1500)

HR 100-120

SBP 80-100 mmHg

Restless

Weakness

Sweating

Class III Hemorrhage (1800cc)

HR 120-160

BP <90/45 mmHg

Cold skin

Respiratory rate 30-50/min

Oliguria

Pallor

“From my cold dead hands.”

3/21/2016

9

Class IV Hemorrhage (2400cc)

HR > 120 bpm

SBP < 60 mmHg

Altered consciousness

Anuria

Absent peripheral pulse

Air hunger

Case Presentation

18 y/o G-1 P-0 at 22 weeks

IUFD with complete abruption

Large intrauterine hematoma

BP 82/20, P-128

Cold hands and feet

Urine output <10cc past 4 hours

Obstetrical Hemorrhage Protocol

Shields, LE AJOG 2015;212:272

Obstetrical Hemorrhage Protocol

Produce early intervention

Demand on-site presence of physician personnel for patient evaluation

Prevent repeated us of unsuccessful interventions

Ensure early delivery of blood products

Protocol: Maximize the Coagulation System

Prevent hypotension: Large bore IV, IV Fluids, PRBC, Fibrinogen, Platelets

Prevent Hypoxia & Acidosis: Oxygen supplementation, (Oxygen Sat >95%)

Prevent hypothermia: Warm blanket and warm IV fluids

Obstetrical Hemorrhage Protocol: Stage 1

Shields, LE AJOG 2015;212:272

foflrFoley/Urimeter

Keep Patient warm

500 ml/hr

Q 5-15 min

Rule out trauma, tissue, thrombin

3/21/2016

10

Obstetrical Hemorrhage Protocol

Shields, LE AJOG 2015;212:272

>95%

CBC, Platelet count, PT,

PTT, Fibrinogen,

electrolytes, & Creatinine

Red top tube

Type and Cross for 2 units and request 2 u of unmatched PRBCs

Intrauterine Balloon

Insert under ultrasound guidance

Inflate to 500cc with sterile water or NaCl

Use vaginal packing (iodoform or antibiotic soaked gauze) to maintain correct placement and maximize tamponade

Maximum time balloon can remain, 24 hrs

Obstetrical Hemorrhage Protocol

Shields, LE AJOG 2015;212:272

ABG, CVP, PAC, Art

line

Obstetrical Hemorrhage Protocol

Shields, LE AJOG 2015;212:272

Surgical Management

Uterine curettage

Placental bed suture

Uterine artery ligation

Repair uterine rupture

B-Lynch suture,

multiple square sutures

Hysterectomy

Stage 4 (EBL > 2400 mL)Cardiovascular CollapseProfound hypovolemic shock prior to blood loss replacement or amniotic fluid embolus

Consider surgical intervention to ensure hemostasis (hysterectomy) with aggressive blood AND factor replacement

Expeditious hemostasis is critical

3/21/2016

11

Obstetric HemorrhageMTPActivated by lead physician, (>4u PRBC given or > 10u PRBC expected in 12 hrs)

≥4 units of thawed FFP are available at all times at the blood bank

Obtain Massive Transfusion Pack in cooler, (4-4-6u PRBC, 4u FFP, 1 apheresis pack of platelets), to be sent each time more PRBC requested

Monitor CBC, PT, PTT, Fibrinogen Q 30 min

After two rounds, consider RF Factor VIIa

Massive Transfusion ProtocolStanford UniversityGoal was FFP:PRBC to 1:1.5

Pre-MTP Post MTP p-value

FFP:PRBC 1:1.8 1:1.8 0.97

Plt:PRBC 1:1.7 1:1.3 0.05

PRBC 115 minutes 71 minutes 0.02

FFP 254 minutes 169 minutes 0.04

Platelets 418 minutes 241 minutes 0.02

Mortality 45% 19% 0.02

Riskin, DJ J Am Coll Surg 2009;209:198

Be a Great Team Leader

Be confident and decisive

Look people in the eye and use their name

Repeat back orders

Confirm order are being carried out

Don’t speak to the room and assume you are being heard

Remember to express gratitude

Support Program for Patient’s Family and Staff

Timely information and reassurance

Opportunities to discuss the incident

Referrals to support services

Caring and supportive words and actions

4 Domains of Patient Safety Bundles

Readiness

Recognition and Prevention

Response

Reporting/Systems Learning

Obstetric HemorrhageReporting/Systems LearningResponse

Culture of huddles and debrief for high-risk patients and post-event debriefings

Multidisciplinary review of all stage III hemorrhages for system issues

Monitor outcomes & processes metrics in perinatal QI committee

3/21/2016

12

What is the most common reason women die from postpartum hemorrhage?

Delayed or inappropriate

correction of hypovolemia

What is the most common reason women die from postpartum hemorrhage?

Doing surgery on a patient

without knowing her

coagulation status

Severe HemorrhageKey Points

Recognize early, Triggers

mental status change (acting funny, “she ain’t quite right”),

Oxygen saturation <95%

Hypotension (SBP < 90mmHg, <85/45)

Tachycardia: >110 bpm or 15%

Oliguria: < 30cc/hr

Severe HemorrhageKey Points

Volume replacement

2 X IVF for EBL

keep SBP > 90 mmHg

Fibrinogen >100mg/dl

Hct at 24-30%

Platelets 50-100K

Temperature >95 degrees F

Keep INR < 1.5

Questions

Hemorrhage

Blood Products

Type Volume Effect/Unit

PRBC 240ml Hct 3%

Platelets 50ml 5-10,000/ml

FFP 250ml Fibrinogen 10 mg%

Cryoprecipitate 40ml Fibrinogen 10 mg%

1

Planning Surgery for

Pelvic Organ Prolapse

Bob L. Shull, M.D.

Professor of Gynecology

Department of Obstetrics and Gynecology

Scott and White Memorial Hospital and Clinic

Texas A&M Health Science Center

Temple, Texas

USA

Disclaimer

My spouse and I have no relevant

financial relationship with a

commercial interest in any of the

material contained within this

presentation.

Learning Objectives

At the completion of this session, the participant should:

1. Recognize the need for accurate assessment of

the specific pelvic support defects.

2. Understand how to evaluate 5 specific vaginal sites

• Urethra

• Bladder

• Cervix or cuff

• Cul-de-sac

• Rectum

3. Understand how to plan the surgical approach

for pelvic reconstruction

2

Genesis 11: 1-9

These are all one people and speak

one language... soon they will be able

to do anything they want! Let's mix up

their language so they will not

understand each other.

Language of Pelvic

Support Defects

• Subjective

• Inaccurate

• Non-specific

Requirements for Improvement

• Define

• Normal

• Sites to be described

• Conditions of examination

Goals

• Assessment of specific sites

• Description of support loss with

maximum stress

• Anatomic abnormalities contributing

to support loss

• Reproducible

• Understandable

• Usable

• Improves patient care

Staging

• Oncology

• Clinical

• Surgical

• Infertility

• Surgical

3

4

Physical Findings

Normal Physical Exam

Genital hiatus

Closed

Urethral meatus

parallel to the floor

no evidence of urethral prolapse/caruncle

Anterior compartment

Cervix/Cuff

Posterior compartment

Neuromuscular assessment of pelvic floor

Gynecologic pelvimetry

Normal Pelvic Exam

Cuff and

uterosacral

ligaments

Gynecologic

pelvimetry

5

Abnormal Pelvic Exam

At Rest Straining

Open genital

hiatus

Anterior Compartment Defects

Am J Obstet Gynecol 2002, 187:93-98.

Transverse Cystocele

Anterior Compartment & Apical Defect Post Hysterectomy Cuff Prolapse

6

Posterior Compartment Defects Posterior Compartment and Apical Defects

Perineal Descent Rectal Prolapse

Results

• Office Evaluation

• Document symptoms

• Objectively describe physical findings

Objective Clinical Evaluation

GRADEGRADE

SITE 0 1 2 3 4 COMMENTS URETHRA BLADDER CERVIX/CUFF CUL-DE-SAC RECTUM PERINEUM

SITE 0 1 2 3 4 COMMENTS URETHRA BLADDER CERVIX/CUFF CUL-DE-SAC RECTUM PERINEUM

Q-tip °deviation from horizontal Subpubic arch Resting______ < 2 finger breadths_____ Straining_____ = 2-3 finger breadths_____ = 3-4 finger breadths_____ Vaginal Atrophy Yes_____ > finger breadths_____ No_____

Q-tip °deviation from horizontal Subpubic arch Resting______ < 2 finger breadths_____ Straining_____ = 2-3 finger breadths_____ = 3-4 finger breadths_____ Vaginal Atrophy Yes_____ > finger breadths_____ No_____

7

Visceral and Sexual Function

BLADDER Urinary Incontinence

Genuine incontinence

Detrusor instability

BOWEL Anal Incontinence

Anal sphincter intact

Constipation requiring splinting

SEXUAL FUNCTION Sexually active

Desires to maintain or enhance sexual function

BLADDER Urinary Incontinence

Genuine incontinence

Detrusor instability

BOWEL Anal Incontinence

Anal sphincter intact

Constipation requiring splinting

SEXUAL FUNCTION Sexually active

Desires to maintain or enhance sexual function

YES NO COMMENTSYES NO COMMENTS

Results

Management Options

• Observation or medical therapy

• Longitudinal change in symptoms

or physical findings

• Surgical management

• Plan approach based on objective

physical findings

• Integrate intraoperative findings

• Design repair specifically for defects

Results

Long Term Follow-up Comparing

Site-specific Physical Findings

• Prognosis for success or failure

• Modification of technique

• Accurate communication with

others

At the completion of this session, the participant should:

1. Recognize the need for accurate assessment of

the specific pelvic support defects.

2. Understand how to evaluate 5 specific vaginal sites

• Urethra

• Bladder

• Cervix or cuff

• Cul-de-sac

• Rectum

3. Understand how to plan the surgical approach

for pelvic reconstruction

Learning Objectives

Bibliography

1. Shull BL: Clinical evaluation of women with pelvic support defects. Clinical Obstet Gynecol, 1993, 36:939-951.

2. Shull BL, Benn SJ, Kuehl TJ: Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome, Am J Obstet Gynecol 1994;171:1429-39.

3. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Smith ARB: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol, 1996;175:10-7

4/1/2016

1

NC OBSTETRICAL & GYNECOLOGICAL SOCIETY

NC SECTION OF THE AMERICAN COLLEGE OF

OBSTETRICIANS & GYNECOLOGISTS

MEDICAID REFORMfor North Carolina

Donny C. Lambeth

NC House of Representative

April 8, 2016

1

WHY REFORM?

2

Let’s begin by looking at

the numbers . . .

3

MEDICAID REFORM

Why Reform/Re-engineer

Increasing enrollment

4

MEDICAID REFORM

Why Reform/Re-engineer

FACT: In NC, Medicaid enrollment has

significantly outpaced population growth

trends.

5

NC MEDICAID ENROLLMENT

6

Medicaid Enrollment (10/1/15) 1,820,818

Health Choice Enrollment

(SCHIP – 10/1/15) 78,138

NC Population (7/1/14 estimate) 9,953,687

SOURCE: Division of Medical Assistance and Office of State Budget and Management websites

4/1/2016

2

NC MEDICAID ENROLLMENT

7

NC ENROLLMENT COMPARED

TO POPULATION

8

1.0

1.1

1.2

1.3

1.4

1.5

1.6

1.7

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Cu

mla

tive

% G

row

th F

om

2003

NC Medicaid NC Population

MEDICAID REFORM

Why Reform/Re-engineer

FACT: In 2009, NC spending on a per

member per month (PMPM) basis began

to trend significantly differently than the

trends in the rest of the country.

9

MEDICAID REFORM

Why Reform/Re-engineer

Legislators desired higher level of budget

predictability and confidence.

10

TOTAL NC MEDICAID SPENDINGCLAIMS, ADMINISTRATION, CONTRACTS, SETTLEMENTS,

PROGRAM INTEGRITY, TRANSFERS AND OTHER SPENDING

$2.0 $2.0 $2.4 $2.5 $2.6 $2.9 $2.8 $2.3 $2.5 $3.0 $3.1 $3.4 $3.5 $0.4 $0.4

$0.4 $0.5 $0.5 $0.4 $0.2

$0.7 $1.0

$0.8 $0.3

$0.6 $0.5 $0.5

$4.8 $5.9

$6.6 $6.6

$8.1

$8.3 $8.9

$9.2 $9.5 $9.5

$8.5 $8.3

$9.0

$1.2

$0.5 $1.6 $1.2

$-

$2.0

$4.0

$6.0

$8.0

$10.0

$12.0

$14.0

$16.0

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

in B

illi

on

s

Appropriations County Share ARRA Shortfall Receipts UPL/GAP Plans

SFY 2014-15 does not include the $186 M contingency reserve budgeted

Source: NC Office of the State Controller and NCAS BD701

14 12

GENERAL FUND APPROPRIATIONS COMPARISONS2010 -11 to 2014 -15

CATEGORY 2010-11 BUDGET 2014-15 BUDGET SPENDING

INCREASE

PERCENT

CHANGE

TOTAL $ 18.958 B $ 21.069 B $ 2.111 B 11.1%

MEDICAID – State

share only

$ 2.466 B $ 3.688 B $ 1.222 B 49.6%

OTHER – State

Appropriations

$ 16.492 B $ 17.381 B $ 0.889 B 5.4%

4/1/2016

3

MEDICAID REFORM

The true picture

FACT: Medicaid increasing at a rate three

times the State’s revenue growth.

13

ACTUAL STATE SPENDING

COMPARED TO BUDGET

14

NORTH CAROLINA’S GOAL

NC desires to move . . .

FROM TOWARD

Reward for volume Reward for value

Budget uncertainty Budget predictability

Sick care Health care

Risks by State Shared Risks

15

BY CREATING A PROGRAM THAT . . .

Leverages investments NC has already

made.

Embraces both short-term and long-term

ideas.

16

BY CREATING A PROGRAM THAT . . .

Rewards Innovations.

Focuses on wellness, preventive services.

17

BY CREATING A PROGRAM THAT . . .

Provides budget predictability.

Cares for the whole person, improves access,

enhances quality care and patient satisfaction.

Increases administrative ease/efficiency.

18

4/1/2016

4

MEDICAID REFORM

The Vision

Quality, Compassionate Care – efficiently

Evolution from Fee-for-Service to

Fee-for- Health

Provider-Led Supporting Evidence-Based

Care

Improving Access Across the State

Rewards Key Performance Indicators

19

Based on a capitated risk adjusted

payment methodology with shared

incentive payments built around:

Quality, Access, Satisfaction and

Financial Metrics.

20

North Carolina Will Use a Structure

21

MEDICAID TRANSFORMATION AND

REORGANIZATION

HB372

A new care delivery system with a new

financing mechanism.

1) Beneficiaries will select a Prepaid Health Plan

(PHP)

- Provider-led Entity (PLE)

- Commercial Plan (CP)

- Statewide – up to three CPs/PLEs

- Geographically up to ten PLEs only

22

KEY ELEMENTS

2) Protects essential providers i.e., Federal

qualified health centers, free clinics, public

health departments, by requiring their

participation.

23

KEY ELEMENTS

3) Protects providers to ensure the rug is not pulled out from under them on rates by setting

rate floors.

24

KEY ELEMENTS

4/1/2016

5

4) Establishes a medical loss ratio of 88%

to direct patient care, 12% limited to

administrative overhead and profits.

5) Establishes a robust Health Information

Exchange.

25

KEY ELEMENTS

6) Creates a transition reserve as North

Carolina moves from fee-for-service

to full-risk capitation.

26

KEY ELEMENTS

7) Timeline sets Federal waiver preparation for

submission June 2016; Federal negotiations

of waiver – up to two years (June 2018), ten

PHPs have two years to finalize

organizational structure plans.

Anticipate: Go live no later than July 2020

27

KEY ELEMENTS

8) 95% of eligible Medicaid-covered lives must

be covered.

9) State will ensure coverage of every county

(3 statewide/10 regional).

28

KEY ELEMENTS

10) Limited carve-outs, except for pass through

funds for Behavioral Health, Dental Care,

Dual Eligibles.

11) Preserve pass-through funds (GAP, UNC,

VIDANT).

29

KEY ELEMENTS

12) Behavioral Health continues to enhance its

network – improving on existing care.

Capitated funds determined by State and

flow through prepaid Health Plans.

13) Creates a new State Agency (Department of

Health Benefits) under DHHS.

30

KEY ELEMENTS

4/1/2016

6

14) State establishes the benefits levels, cannot

change unless approved by Legislation.

15) State retains enrollment risks.

16) Costs targets set at two percent growth below

national average.

31

KEY ELEMENTS

1) Taking an innovative approach, North Carolina

will draw upon the best practices and advances

in models of patient care – Innovations Center.

32

What are NC Medicaid Expectations?

2) Primary Care Physicians will serve as the

“medical home” to assure improved

coordination of care and lead the

transformation.

Each beneficiary will select or will be assigned

a Primary Care Physician.

33

What are NC Medicaid Expectations?

3) Reducing dependence on high-cost sites;

instead, patients will be at home or lower cost

alternatives where they wish to be.

4) Reward more efficient models of care with a

focus on quality and access to care.

34

What are North Carolina Expectations?

5) Expand utilization of more efficient care, e.g.,

Telemedicine, medical homes, while integrating

care across all silos of providers.

6) Create competition between CPs and PLEs –

reward change in delivery of care model.

35

What are North Carolina Expectations?

Take cost out of the system – bend the cost curve.

Pay based on value – quality and cost (not volume).

Support evidence-based care.

Expand access – but only with reduced costs.

36

NC – MEDICAID

A Philosophical EvolutionFEE for SERVICE FEE for HEALTH

4/1/2016

7

Establish integrated healthcare organizations to

accept risk, deliver care, and share in rewards.

Self-govern and self-manage; providers control

their own destiny.

37

NC – MEDICAID

A Philosophical EvolutionFEE for SERVICE FEE for HEALTH

Develop robust analytical data systems to manage

care/risk.

38

NC – MEDICAID

A Philosophical EvolutionFEE for SERVICE FEE for HEALTH

Reduce high-end imaging.

Reduce emergency department inappropriate

utilization.

Increase generic prescriptions.

39

OPPORTUNITIES

Reduce the 30-day readmission rate.

Reduce unnecessary utilization, duplication.

Improve quality care; reduce costs.

40

OPPORTUNITIES

Reduce hospital acquired infections/stays.

Enrollment of “frequent flyers” in medical homes

with aggressive care management.

Promote treatment in the lowest cost

setting/facility appropriate for care.

41

OPPORTUNITIES

Eliminate silos to more efficiently integrate care.

Promote wellness and preventive care.

42

OPPORTUNITIES

4/1/2016

8

Improve infant mortality and high costs associated

with complicated births.

Significantly expand innovative care utilizing new

technologies.

43

OPPORTUNITIES

THANK YOU

AND

QUESTIONS

44

Representative Donny C. Lambeth

North Carolina House of Representatives

75th District

300 N. Salisbury Street

Raleigh, North Carolina 27603

(919) 733-7547

donny.lambeth@ncleg.net

45