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North Carolina Healthcare Quality Alliance

In April, North Carolina Governor Mike Easley announced the North Carolina Healthcare Quality Alliance (NCHQA), a plan to standardize care across the state for five of the most common and costly chronic conditions. A collaborative effort involving the state's physicians, hospitals, insurers, and other stakeholders, NCHQA is intended to improve health and reduce medical costs.

The NCHQA involves a three-pronged approach:

  • getting payers to agree on one set of quality measures;
  • providing support to physician practices to implement the evidence-based guidelines; and
  • collecting and reporting data on provider performance relative to these measures.

According to Mark Holmes, vice president of the North Carolina Institute of Medicine, "getting stakeholders to agree and 'buy into' standards is a long process, but is critical to ensuring success." Through efforts over the past two years, North Carolina provider organizations and three major insurers—Blue Cross and Blue Shield of North Carolina, the state employee health plan, and Medicaid—have approved 20 performance measures developed by state and national experts for diabetes, asthma, hypertension, heart failure, and heart attack. The preliminary asthma measures are presented in Figure 3 below, and the full set of measures can be found at The measures are generally based on recommendations by national organizations. These initial measures will be modified as new evidence emerges, and additional conditions will be added over time.

Figure 3: Initial Quality Measures—Asthma
Eligible Patients:
  • 5–40 years old
  • Diagnosis of asthma based on:
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient, or emergency department visits (specific CPT or revenue codes)
    • specific subsets of patients for measures applicable to patients with mild, moderate, or severe asthma
    Quality Measures (endorsing organization):
    1. Patients evaluated during at least one office visit for frequency of symptoms (American Medical Association Physician Consortium for Performance Improvement)
    2. Patients with mild, moderate, or severe (stages II–IV) asthma on preferred long-term control medication (AMA)
    3. Patients with mild, moderate, or severe (stages II–IV) asthma have asthma action plan in chart or documented that was given to patient (AMA)
    Data Collection:
    • Claims data used to identify a panel of eligible patients for each practice.
    • Chart audit at practice to:
      • Confirm diagnosis and exclude those without asthma
      • Determine subset of patients for measures 2 and 3, i.e., patients with >Stage I asthma
      • Obtain information for measures
      Source: Quality Measures used in the Governor's Quality Initiative,, p. 3.

      Currently, seven quality improvement consultants from Area Health Education Centers (public–private partnerships in nine regions throughout the state) are working closely with 50 to 60 primary care physician practices, providing individualized support to improve quality. This involves special training to clinicians and staff to incorporate the clinical guidelines in daily practice. Also, the primary care providers receive tools that facilitate patient education and software to track patients, appointments, medications, and test results. The approach builds strongly on strategies developed and piloted through Community Care of North Carolina, the state's system of community health networks providing primary care case management to Medicaid recipients. [1]

      The three major payers in the state (Blue Cross and Blue Shield of North Carolina, the state employee health plan, and Medicaid) will submit data to a centralized data repository scheduled to be operational later this year. The participating physician practices will receive annual reports on their performance on the 20 clinical measures to help them identify areas that require improvement. Over time, standardized quality measures should reduce the burden on physicians of submitting different data sets and meeting different performance criteria, depending on patients' insurers.

      Officials acknowledge that there is a long way to go to reach the 2,500 physician practices in the state. "A challenge is how to expand this program in a way that is sustainable," says Holmes. One approach may be to offer different levels of support, depending on the needs of the practice. Another is to develop "networks of networks" to branch out through the state.

      The NCHQA has a two-year budget of nearly $8 million. The three major payers noted above each pledged $2 million, and the remainder is funded by the state's Health and Wellness Trust Fund (tobacco settlement funds) and other sources. [2] Officials expect that progress over the first two years will bring additional insurers and funding in future years.

      [1] Also, the effort builds upon a program operating in two regions in the state last year under the Improving Performance in Practice initiative, which was supported by multiple funders, including the Robert Wood Johnson Foundation.
      [2] Other sources include the Center for Health Care Strategies and the National Governors Association.

      For More Information
      See: North Carolina Healthcare Quality Alliance's Web site
      Contact: Mark Holmes, Ph.D., Vice President, North Carolina Institute of Medicine, [email protected].

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