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Joint | March 31, 2015 | Chamber | Health and Human Services

Full MP3 Audio File

Good morning. Welcome to the Joint Appropriations Health and Human Services Committee Meeting, this morning. I appreciate all of you being here. First of all, let me introduce our pages Martha Blan, are you here Martha? Wide awake and glad to be here, I can see that. She's from Fay Ables, sponsored by Senator Meridith. Adele Patten, one of the triplets, is that correct Adele? Alright, thank you. She's from Concord's Santa Barbara, and then someone she knows how to ross pattern, her twin sister from Concord for Senator Hartsell. How about Elijah Ellison. Elijah, good morning to you? Glad you're here. He's from Durham from Santa Woodard, and then Nathan Oakley? Nathan? He's from Durham as well, Senator Woodard, and then on the house side, Alex, Alexus Gardener Hello, good morning to you? Always glad to be up this early in the morning even though I'm a teenager. Cumberland County Marvin Lucas and then Stewart Haze, from Wilson, Susan Martin, Stewart thank you for being here and as always the gentlemen that keep us online gentlemen and ladies in the house, Sergeant at Arms Bill Morris, Jim Morain[sp?] and Joe Cook. Thank you gentlemen for being here, and on the Senate side [xx] Louis and Martin Kits, Martin is a short, very short sergeant in arms there. This morning we are going to hear from staff Steve Owns[sp?] who is on the physical research team here that deals with HHIS along with Susan, and Jennifer, and Denise, we appreciate your efforts in dealing with such a complex issue, you try to help us understand what we're up against and to add value to what we appropriate dollars to Bonaire[sp?], you ready? I am Sure we'll turn it over to Steve, well thank you, Thank you Mr chairman, and member's of the committee. What I want to do is really kind of complement some of the information that you've heard from other presenters, and really focus down on the medicaid side of mother's babies, and the medicaid expanding. I'm going to really present a lot of information that has come from the department this is really a much better data presentation, I'm going to talk about the period of trans and births, c-section rites, infant birth weights, transant spending, and really kind of come to some observations and talk about next steps. I guess one disclaimer, this presentation probably raised more questions than the answers. Well there is a lot of information, there is a lot of fusses and a lot of things going on, so I think we'll probably end this session with a lot of questions that don't get answered during this presentation. when we look at births in North Carolina, it's a couple of things. The dotted line really shows the number of births since 2004 to 2013 that North Carolina has had across the state. The red line shows the percentage of those births that medicaid has covered. Clearly what you see between 2004 and 2009 the percentage of births that medicaid was covering was increasing to about 50% 2004, to about 57% 2010 that's primarily a function of the number of births that medicaid was, of the 120, 130, 000 births in the state, medicaid was covering in 2004 about 61, 000, 2009, they're actually covering almost 74, 000 births. In 2013 they covered about 67, 000 of the approximate 120, 118, 000 births. So basically what was happening is Medicaid births were rising at a rate faster than the rest of the state and I feel they maintain at least really flat in terms of the comparison they have with stateless trending after 2009. This map presents basically a distribution of births across the State and I've broken the births into four quartiles, the highest quartile which is the yellow counties show those counties that have the highest percentage of births covered by medicaid, so in that highest quartile, between 78.5% and 100% of the births covered by medicaid, Martin county actually in 2013 medicaid cover 100% for every baby that was born in that county was covered by medicaid.

You go down in the second quartile in terms of third quarter between 68% and 78% of the births were covered by Medicaid, the lowest quartile between 23% and 50% 8% were covered by medicaid. In 2013 again approximately 57% of the total was recovered by medicaid. The lowest county in that year was Onslow County with about 23% of the gross covering medicaid. So again what you see is in terms of just patterns the counties in the South and Eastern part of the state have the highest percentage of those covered by Medicaid. Typically the counties in the Northern and Western parts of the state have the second highest level of births covered by the medicaid. We talk about C section rates and C section rates typically are one of those things that we look at because it was how does that affect cost? How does that affect births. In terms of couple of observations what I've shown you here from 2004 through 2014 the black line shows the medicaid percentages of births that were done by C section. The dotted line shows 2004 through 2013 at the state level what percentage of births we at, all births in the state were performed by C-section. Generally Medicate births during this period of time, a lower percentage of those births were delivered by C-section. Obviously, you can see that as Medicate trend goes so will North Carolina trends go. Beginning in 2009 we saw of flattening and we saw a really consistent rise in Medicate births per C-section for 2009 but after that point and time we actually began to see some moderation, some decline in the percentage of births that were delivered by C-section. One of the things that you'll see in [xx] is there are a lot of activities that the State has implemented, there are a lot of programs that are external at least to the State government through a variety of other organisations, they're focused on birth whether trying to elimate three [xx] or just stationed trying to do a number of things with 17P and a number of activities that are focused on births. The data really doesn't provide information, at least the data that I've gotten from the department doesn't really give us information to say this was a specific thing that led to the specific outcome in this case sub C-section rates declining or moderating. This map tries to show again the hospitals have nurseries that have different levels of complexity or the ability to deal with complex cases. Level 3 and 4 nurseries are your highest level nurseries in terms of their ability to deal with the inmates or severely ill children. What I've tried to show is the distribution of those nurseries across the state, the Purple counties [xx] have birth they havee and four level nursery pink counties are those that only have a level four level nursery, and the blue of those counties have only a level three level nursery. That gives you some sense of how those particular facilities or those particular resources distribute across the state. Well things I did is I went back to the health service regulation to look at how have those facilities particularly the three in the four level facilities been utilized over recent years. Between 2009 and 2010, I guess that really happened till 2011. We saw fairly stable or consistent level of days reported, that was the number of days of stay within those level three and four nurseries. For babies, for all babies across the state during that 9 to 13, 11, excuse me, it's really stable. Beginning at 12, we began to see the reported days rise 13  you see a fairly sharp rise in the number of days reported for this level here. one of the questions that I'll probably leave you with as get through here, there's a number of unanswered questions. One of the unanswered questions we look at days [xx] is you'll see in a minute the average birth rate for babies is increasing or has in recent years. So one of the questions is you look at the day that is what's the correlation between the use of the level three and four nursery days and there's increasing growth rates, is there

a correlation, should there be a correlation is the growth in the rate a function of longer stays in the nurseries, that growth and days a function of more admissions to those nurseries really whats causing, that growth if you will when we actually see the weights of babies going up at the same time. This is another map and again the dots in this map go to the map I showed you earlier, shows the location of all the level three and four nurseries across the state. The color counties begin to show what percentage of the births, and this I believe was 2012 information. What percentage of the births in those counties were in what were classified as low growth weight babies. So again in the white counties, those counties had between 5.7 and 7.1% of the babies born in that county were in the lower birth weight, very low birth weight category. The blue county is on the other end of the spectrum where those counties have had between 10.7 and 14.2% of those babies born in that lower birth weight counties. So these are the counties that have the most significant need, in terms of being able to access the higher end, nursery key in the higher end of obstetrical care. As I mentioned earlier, I'm going to shift now from mothers to babies. The charts here have segregated the babies into three categories. Babies that were born with less than a 1000 grams, and again to give you a gram comparison, basically a pound equals about 450 grams, so a 1000 grams is basically two [xx] two pound baby. A 1000 to 2500 gram and then 2500 grams and above in terms of the birth weights. As you can see the black line is at final category the babies born weighed more than 2500 grams which again is about five pounds in terms of average birth weight. In 2005 we had about 91% of our babies in the state, or Medicaid babies excuse me, were in that and above 2500 grams. At 2014 you can see that risen to around 93% again this is a positive trend we've seen the average birth weights going up you can see where the other two lines, the red line or the lowest weigh that less than 1000 grams. The blue line are those babies between 1000 and 2500 grams, the majority of the shift if you will into that higher [xx] category coming out of that 1000 to 2500 grams which is not surprising. The chart in the bottom right, what I try to give you again is that a couple of all other comparisons since in 2012, a very low birth weight babies, those classified as 1500 grams and below, were about the same as they were, actually a little better than there were North Carolina a little not as good as they we're across the US. You can see the birth weights are less than 2500 grams we were slightly, medicaid was slightly higher than the state, much higher than US, but by 2014 you can see the significant change, and those were the percentage of babies that were born covered by medicaid that are in that less than 1500 grams and not less than 2500 grams category. The significance I think of this, and what you would intuitively think is we see the birth weights go up, we should costs coming down. The chart underneath the [xx] on the left shows you basically what medicaid pays for babies that are born less than 500 grams, the average cost in 14 was around $39, 000. The average cost of babies between 500 and 749 grams was about $130, 000. The average cost of the baby 2500 grams as you see was about $5, 500 the reason they're less than 500 grams is so much less than the 749 grams again is the proportion of those babies that don't survive so again you can see is [xx] as we move up that scale in terms of weight, we would expect costs to follow that trend in terms of overall cost and the cost I show here are really the cost for the first year of life, to deliver the baby plus the first year of life. So this is kind of more comprehensive what we're actually spending for babies not just the delivery. When I look at costs what I have is really plotted is and this is the total cost that medicaid pays for each birth.

It includes the mother Prenatal cost, it includes the delivery cost, it includes the cost, to CCNC for pregnancy medical home. It includes the cost for the child but through the delivery as well as the first year of life. One of the things I get an email last night about nine o'clock to indicate that the 2013 data I had been provided has some duplicate information on it. So the department is trying to work through the that so that it can reinstate this and give you updated information, but even if you throw that data out lets's ignore 2013 at this point. What you see is basically a moderately increasing trend cost. In 2005 we were spending less that about for medicaid babies, a little less than $10, 000 for those babies. In 2012 it was right around $11, 000, again a moderately increasing rate of growth, and as you'll see in the red, based on the data I have received look like the growth in 13 was primarily in hospital and physician costs which were representing about a $2, 300 per baby growth during that period time we will go back and restate that once, we actually have updated information or new information. Again, this really showed us, I guess this really shows it tried to break a call, break apart the call, break apart the cost for the baby versus the cause of the mother, again if you put 2013 aside, what you see is a cause for the mother, actually from 2000 forward 2012, was flat to declining. We're actually getting C-Section rights group. going down we were seeing cost for those mothers coming down slightly through that period of time on the other hand what we we're seeing for babies again if you look at 2012 and back, it was a moderately or consistent growth in terms of spending for babies. So one of the unanswered questions is here is is you look at what's going on with cost going back to the baby's way [xx] by a mother's C-section how much of the cost is being influenced by utilization, by rates by consumption or the mix of service or the location of the providers contributing, or location as providers, how much is that contributing to this plans we're seeing for mother and baby cost. This trial has a lot of information and I think the point of these goes back to when you look at, the time when I put this chart together, what I was seeing in 13 is that significant rise and hospital call said it really focused on the hospital payments. Whenever there is an array hospital calls from the impatient perspective to give you what is the cost that medicate pays for normal delivery for C-section with complications, for normal new born, or full time [xx] with complications and for a premature [xx] with complications, what is it that medicate pays, medicate pays at base rate at times they the DOG way, or flat amount for this services. The difference in rates today, really all hospitals other than teaching hospitals or teaching affiliates is a flat rate of $2700 as the base rate so you can see for normal delivery and in most hospitals in his state we play about $1860 for the mothers delivery we would obviously pay for the normal newborn about $545 so that's the cost within the hospital. Whatever rate above that again with the teaching facilities. The teaching facilities give that [xx] plus and add on for [xx] medical education so a baby born a normal new born delivered in UNC for instance the state pays about $ 3100 normal newborn in a non teaching hospitals state pays about $860 but where the services are provided will affect what medicaid pays for the cost of [xx] in terms of client and then this claim cost them. So as you look at cost and the transcend cost one of the factors to look at when you're looking at hospitals is which hospital provide plus the mix or DRGs where does it fall in that spectrum, at least this is just fro the click of DRGs that could fall in other outlines, well there are a number of factors, those are the things that I think are unanswered now that we have this kind of [xx] to drill down and really understand how these factors are changing, how the mixer services are changing. Again, this is cost.

What I've done here is the blue line again is what I'm calling absolute cost, that is you take the total claims for prenatal, for delivery, for CCNC pregnancy home plus the first year was, what do we actually pay with the medic aid that's the blue line. It's also important to realize during that great a time we were also the general assembly reducing rays. So those ray reductions were built-in into the constraints when you look at the actual claims so when I began the normal hours or just for that, again even if we put 2013 aside, what you see is that gradual increase that we were looking at before before 2005 and 2009, particularly in 2009 begins to accelerate faster so our cost actually in real terms, or growing in much more rapid rate even at the same time or the same growth rates go up and C-section rates go down. This is a lot of stuff up here, this chart tries to blend the graph on the right the blue and red lines are same lines you've seen before that's the average cost per delivery. The green line is the in what portion the babies that are born 2500 grams and above.  So you can see as it was rising or going down, 2011 actually caused, we are still going up at that point. I tried also to pick up three programs, one was called pigneck, Durham Connects as well as pregnancy home and when those things were being implemented, not trying to attribute either success or whatever to any of those programs, those were just other environmental factors, things were going on outside the State if you will in terms of what Medicaid was doing specifically, other than pregnancy home, they were happening concurrently with this. The Durham Connects really focuses on in-home post delivery nurse home, nurse visits to peoples home in Durham County. Picnic has a variety of things that it does. One of the most significance things was doing was really focusing on how to eliminate the elective 39 week, delivery trying to eliminate this 39 week gestation periods. Pregnancy home was really trying focus on again C-section rates how to improve the growth weights for babies and you would see there were variety of things both in terms of population management payments, as well as those physicians around trying to encourage participations program. Again when I look at the data one of the unanswered questions that I can come away with is if birth weights are increasing? If c-sections rates are declining, What is causing these average cost to change. I think it's one of the things we need to spend the time to understand. In summary what does the data tell us? The good news is that birth weights are rising and have risen recently at the same time though we're seeing reported hospital days for new units for neo natal intensive care units level three and four is rising what's causing that. C-section rates have started to decline or recede [xx] years in a [xx]. Absolute spending for a pre-natal delivery CCNC in the first year of cause, looked very flat in terms of absolute dollars but when you begin to normalize for rate reductions that the general assembly has improved what you see is the primary factor for holding that down, appears to be those changes. We actually seen some growth and the average cost. So I guess and I've talked about some of the unanswered questions before but as you go in summary I think one of the questions or some of the questions are, what is or should the relationship, in between a birth ways, c section ways that is cost in level three in four days? Second question is who is or should be looking at health outcomes for mothers and babies and cost from a system perspective. Looking at the overall resources you have overall cost overall outcomes what is it that North Carolina should be investing and to improve those outcomes, and lower costs, and then leave it with, kind of, what should be our next steps. As I strudel my caveat, I think I probably raised more questions I'll answer with this presentation, but happy to try to answer other questions. Thank you, Mr. Owen. Are they questions from Flex here? Coach here Abel go ahead. Thank you Mr. Chairman.

It always looks really strange when you got a line that moves, and all of a sudden you got a real sharp direction either up or down. Were there any things that didn't have anything to do with medical that were in departmental, in terms of changes in reporting issues with NC tracks, and data from collection? Where're we getting this data? How much of it is impacted by those sort of things? How much of it? I've noticed you got information from other sources as well that wouldn't be impacted by that. In terms of NC tracks, all the data and thus far will they precede at NCTracks. NCTracks started July 1st, 2013th, so again all this data really precedes that. Okay, last night I found out that the department identified some duplication of claims in that. I can't tell you the extent that exist and what the issue was there. What I've requested and receive from the department tell me all the claims that we paid for each mother that delivered a baby, both prenatal and during the delivery process, how much did we pay for to CCNC pregnancy home, then how much did we pay for each of those babies born for the delivery into the first year of life. So what I've got here for all the claims that are coming out of the claims systems that we also used North Calorina birth certificate information to [xx] against that information to try to make sure we had good data that won't help us with the claims it will help us with C-section rates and birth weights that kind of stuff so I think that's good data. And I think prior to 13 I feel fairly confident that what I've got is a complete set of data but I can't ask for it directly. The issues with the days and the chart that you had can you not drill down per unique event and determine what the length of stay it was, or is it just a total bad days. The bad days that reported here really come from the health service regulations division, this are days reported by the hospitals, your question's is exactly right on, what we need to do is now I can tell you about facility what we need to do is step back and look at the number of days that are actually being captured within the claims and understand how Medicaid is contributing to this, was this other cases rather, maybe other than medicaid Thank you Mr. Chairman, Miss Darwins when did CCNC begin the full implementation of their pregnancy home model? What I recall is that was implemented in April 2012, Looking at kind of the first year that kind of we have in these costing coming in, and I understand the things that you have in the data, is there any indication that that can be or, would even conceivably be the cost savings that was promised, and to the state by implementation of that program.? They were cost savings programmed in for that, and the costs according to the data I have, have actually risen. The only thing that seems to be happening at the same time are birth rites and c- section rates, those two seem to be moving at least in positive trends from that point forward. I can't necessary correlate is that exactly while that happened on the cost side like I said there were costs savings anticipated that it doesn't appear at least based on the claim study that we've seen savings and costs. Follow up [xx] Miss Jakes[sp?].   Senator Tucker members of the committee if I can add one thing I think. One thing we've realized in looking at all this data including trying to figure out whether CCNC or this other programmes would save any money. I think what we have to try to figure out is unless you change the way you're going to pay for medicaid. We don't know that you will achieve the savings. There's going to be a connection we think between what you implement to try and achieve savings and outcomes and what you actually see those savings in the medicaid program may depend on whether your reform your payment. How you pay providers within the medicare systems. So I think it will be difficult for us to answer questions on in any of these programs, that are dealing with improving outcomes until we try to figure out how it impacts or how

providers respond to those changes as far as I guess implemented within the medicate partner Thank you Ms. Jacobs, a question for you Ms. Jacobs? and looking at what Steve has shown us though that program was implemented, the [xx] whole model, was implemented in 2012, and 13, and 14 is a straight line to the sky. So, I mean if we're looking and reviewing and looking at return on investment on programs that graph doesn't show me that they promise how model was the are there extenuating circumstances that you realized may or may not be helpful in this overview. Well we say that, first since after that, we want to give act of department an opportunity to come and give us correct data if they need to do that, secondly I think we've seen it would be hard to give credit or blame to any program based on what we've seen. We don't know how these changes are, what's happening to, it doesn't make any sense so as they were saying, improvement in outcome, to me seeing improve in outcome means that something is going right as far as quality initiative is concerned and pregnancy home model should be focused on improving birth weights, lowering c section, the number c section, things like that. If the program is working the outcome should be improving. We seeing improvement in outcomes, we are not seeing reduction in costs and to us that doesn't make. Logically we can't figure that out, so I think that's why we say it's linked to more questions than we have answers but I don't think we can answer that question. I don't know whether the CCNC is working or not. Follow up Senator Rice. And this may get to allegedly specific programs and I want to commend you on the work that you've done going through the department aid in this particular area but this is something that occurred in 2013 we are setting in 2015 and it happened to be the focus of I'm looking at back to five is, this is the first time we've heard this. This is the first time we've seen, part of the reason why [xx] escalated so much in 2013. And so my basic question comes to this, who is looking at this information? Why are we not getting from the department and others a complete analysis of spend at the end of the year, that can identify where costs are being driven up within health care and ways to address that? Why are we saying here two years later and the first we catch it is, it's something that fiscal research staff happen to be looking for for a presentation. Senator Hess, we're hopeful that in the new day that you will find out that the claim that it has a duplication in the data but was not actually a duplicated payment. So I'm hopeful that we'll find is that it wasn't a real escalation in cost associated with this, but just an error in the data that we collected, I don't yet we're waiting to hear back from them to find out. I think what we found out in working with HSS and the school of [xx] and others in trying to put together is, it comes back to the recommendations we made to you last week in this committee room which is we believe that HHS needs a unit who is dedicated, I'll let the department speak for the department's in as far as this particular issue is concerned, but we think they need a unit dedicated to looking at this type of issue on an ongoing basis. It would have special projects, helping agencies set up programs like CCNC said that you know what the outcomes were, establishing the appropriate evaluation tools so that we can answer these questions for the committee, we feel like this is a function that is lacking in in the agency right now and that they need that capacity moving forward from this point. So we've made that recommendation to the committee for your consideration. I would defer to the department on what the their plan is as far as this data issue is concerned. I think Trey is here from Medicaid, Mr Chair. Thank you. Would the department like to respond, if that is so identify yourself for the record please? Yes sir. My name is Trey Sumner[sp?], I'm the Director of Finance for DMA just a couple of comments. One we're going to do work with Steven and staff to find out exactly whats going on with our claims information. The other thing in response to senator Hays comment we agree we need to do a better job of reporting, we plan to do that. I have recently published two internal monthly financial reporting packages. We're reviewing that and  then proving it. The plan is to share that both with FRD, OSPN as well as the co-chairs for feedback and review of our financial information

which would include category of service spending by month. All right thank you Sir for that response, Senator McKissick a couple of questions to you Steve, and I guess Susan might be able to help with this too. When we start talking about the length of stays in these level three and level four facilities. Did anything change? Because when we got the few receipts section being done an increase you would expect to see the trend lines changing in terms of link these days, and any change occur in terms of reimbursement policies that would have affected perhaps why the stage when we increase or anything change that we're aware of when it comes to kind of the pediatric field in term of why a doctor might choose or select I guess to keep the baby there longer. I'm trying to help I guess get to this answer that, I guess Representative Yarborough was also concerned about. In terms of hospital payments, or rather all payment, during this period of time the General Assembly was implementing right reductions, so I think in 2010 for instance hospital rates went down about 6.6% specialty rates I went down about 9% for physicians. In 2012 there was another 2% reduction, in 2014 another reduction so there are reductions that were happening during the school time. I'm not aware of any other that probably would like to comment on other reimbursement changes and methodology that they may have affected, in this case the neonatal intensive care for level three and four nurseries Okay, follow up Mr. [xx] if I could. And I was looking over 2 facilities Mire[sp?] in terms of Duke Regional, and Duke Hospital and it looks as if the course differential there is about $825 depending upon where you went to have a baby. Now, to what incident I guess mothers are free to choose where they go to but do we have any directives or policies that would help people get to quality care facilities but once that might provide similar comparable services at lower cost? in terms of hospital care there are no steering mechanisms they would steer your mothers toward one facility or the other like spot to the mothers obstetrician or where they choose to receive care from. One last follow up Mr. Cure[sp?] would it be something that we could look at doing in terms of policies or initiatives or would that be inconsistent with the way Medicaid is provided and funded to try to create some criteria for getting people into quality facilities but those encourage lower costs rather than higher costs. A couple of things, last session the General Assembly did pass a statewide wide base rate provision within the budget. I think what was originally contemplated was a single rate so basically the rate would be the same, what has been implemented is preserved if you avail the gradual medical education add on which is the only difference in hospital is that gradual medical education add-on that you see in the base rate column here. As long as medicaid is a state plan and program. I'll admit we really don't have the ability to deal with a man. Basically any willing profounder unless we have a waiver I guess if Jennifer wants to out any willing provider that wants to provide services to a medicaid recipient that meets the qualifications, we can speak with that. I was afraid we couldn't intuitively that was suggested but, could the agency, is there, he talks about a plan amendment to perhaps address [xx] is that something we could. Do you know of other stage that have any kind of plan amendments to begin with? I guess we have a uniform rate that probably already covered and I guess that's where we are at this time. The department wants to respond. Yes I'm Rodger Barnes, I'm the deputy director of financing at the state plan, there could be a potential state plan however we would have to take into consideration the freedom of choice, the individual could choose their provider so we would have to preserve that as required by federal law. Interesting to note there on the chart the main hospitals for Duke North Carolina Baptist and you

can say they all have high level [xx] and so they do receive children from all over the state I do know that in working with Duke University their nechu unit when the baby is stable enough reaches a level of lead not need, needing the high levels mark you they work with family and the hospital in that community and transfer the baby back to that hospital, so that they can spend the rest of their timing needed in a low level nursery in the community so that it's easier for the family. Yes. Thank you. representative Viscar[sp?]. Thank you Mr. Chairman on page on slide seven the transfer high levels of care for new borns. Do you know how much of that escalation co-relates with the escalation overall cost desist most of the card risen for the escalation counselling? We really have not drilled down on the data that for understanding. So this is what I do not know about.  Follow up. Yes. I assume you're planning on doing that. Correct. Follow to that so when you do that can you also and maybe this question has been asked in another way. Can you also draw down further in the there are other charges that were made for each one of this you can do and that's your next step also right? We actually have The data broken down by category services which is hospitals versus physicians, versus drugs versus whatever what we'll do is take that even to a lower level with hospitals for instance. It's so important to understand which hospital because that will change the amount we spend will actually take down to that level as well so yes we will do that. And one more question. Follow up.   So CCNC started their program and then the next year we saw the cost go up if I understand correctly when we implemented that program we also increased the per member per month for CCNC and the per member per month comes out of medicaid payments. What can you tell the whether any of the increase in cost is as a result of the per member per month? Some of it would be the cost increase the PMPM if everything else stay the same would have added Maybe $100 to the overall cost. You wouldn't see that there was a steady rise and again I don't want to say the cost increase is correlated to the pregnancy home. The cost is in seals increasing prior to that and it started rising in 2008 and it was fairly started to steady rise when you normalize for rate reductions through that entire period so that it's not just related to one particular item. And so you could actually compare the per month increase and also tease out the improvements that were made through that program and compare the, I 'll be able to talk about the change light, changes when we added that PNP and how that affected the average cost, what I don't have data to do is like correlate. how much pf birth rightness share or birth rites necessarily contribute to changes in cost, we'll do our best to really categorize that into all the components try to figure out as much as we can. Senator Robinson. Thank you Mr. Chair, I have several questions and I want to go back to slide seven, say can you figure out what these cause, your question here is one man is sort of like is infant mortality rate higher because the other factor is can we find out where has infant mortality rate risen? And where we have the levels three and four longer stays or has that decreased, and maybe thats's a factor decreasing the infant mortality rate I know in some counties infant mortality rate has risen we'll take

a look at that I know previous information there was information about the state [xx] infant mortality what I can do when we get back and look this as trying to plot that against this to see we going to have those rates correlated with the changes in reported days. OK follow Mr chair yes ma'am follow up. The other chick the other question two is can we get data on what kind of prenatal services? These mothers who later on receive level three or level four care receive knowing that factors of healthy birth weight have to do with prenatal care and one of the things I want to follow up on that is we look at some of the mothers here, the related portion is which one of these mothers for that their prenatal care in this the cause factored in I see you have it for,  what page are you on senator Robinson?  If you go to 14 if we go to the pregnancy at home, we'll see that you have some prenatal care here effected in but I don't see if [xx] connects understand that's a very good model as what I'm being told. It even shows on your chart, in terms of cost versus outcomes and I'm wondering if prenatal cares included and in all these other models where we even have a lower cost. Senator Robinson, members of the committee and Denise is going to be doing a presentation on all of the list of program that are being done, the prenatal programs that you're referencing, that's the question. The question we have is of these programs which ones are working and trying to apply those to the medicare program, there's going to be a disconnection I think you'll find and we can point to those programs that are evidence based, the question we have is then can we turn around and use those the programs to say all these babies that ended up in a three and four make your unit what kind of service that mother have? Our question will be department wide is HHS using that medicaid data with their public health programs to sync that data up and they may be doing that, we haven't gone that far in presentation yet  but Denys will be presenting on this program that you are referencing. Follow up Mr. Chair the other thing while you're finding that out can I ask if in the postnatal care that's just as important too in terms of continue and help the baby help the mother in preventing future low weight births too. Is medicaid covering lactation support to promote breast feeding, are covering any of that? Medicaid I don't know, I'm asking how long. We don't if can we defer to the corner I'm Dancie Henly, I'm the Chief Medical Officer for North Carolina Medicaid. I'm yes the department does cover lactation services both in the in-patient setting and positions officer okay, thank you, did that answer your question? It didn't quite but you don't cover it postnatal you cover it in the position's office while the patient is being seen, but what after birth, this would be afterbirth lactation consultations services as needed by the mother and infant does that conclude your questions? senator okay, thank you Rayson diavlo thank you. I was going back to spiking the cause and everything I know when you introduce new programs you start doing things you didn't do before on a more regular basis, and since Medicaid is a paid for service is there any type correlation that you can see that when we stared paying attention to in the pregnancy home model the mother and getting more regular care and that thing is do you feel like that would be effect or there is going to turn up as well possibly and this increases. We're still doing them fee-for-service type payment. Again I think your question is very good and that's one of the things that I'll make sure we look at as we get into it. At this point I don't have any information to really answer to know whether there is a correlation here. Thank you John Pematon[sp?]. Thank you Mr Chairman, as you know neonatal services is the most expensive part child birth and a lot of hospital don't have the neonatal unit. You mentioned here that the cost of  neonatal care has gone up, but you really didn't say how much.

And  I was wondering maybe at a later time if you could bring back and say what is this a major cost driver in the prices going up? We'll break that down so that you can actually see how much is the neonatal nursery. versus other calls so we'll actually bring that back to you. Thank you sir. Representative Malone? Thank you Mr. Chairman, I'm looking at this presentation and I'm very happy to see the direction we're trying to take things and the work we're doing towards a very important topic but I have some concerns about what I'm saying and there a lots of unanswered questions, there is a lot of correlations, that I'm wondering which one to correlate wrong data streams I don't know whether or not we could talk to CCNC or sent them a series of questions before providing us this presentation, so we could have may be a little more interactive, anyway some back and forth may be having some more of these answers he's not really happy about that. I don't understand and I know this probably has been going on for a long time and there has nothing to do with what we are doing with medicaid, I don't understand why we utilizing some grams but that's just something I noticed but former grams is worth a pound and babies less than a pound that's a pretty scary stuff, I had to get up at 5 o'clock this morning wanted to take my wife to work she works at white med and we actually talked about the spikes in spending and things like this and she says she spends a lot time on administrative things where she used to work on medical issues and perhaps some of what you're looking is that, but I'm not to sure there are some of our co-relations that will find it, the assumptions were try to bring together, alright. I just not really satisfied with this presentation, thanks. Well, some of it is inadequate data, some of it we don't know whether the data is being tracked or not. Some of it is between a physical staff and DHHS and both are more working together to try to co-relate so we do have the right data, so we can actually look at return on investment on the programs that we do have. Any other questions from anyone else? senator [xx]. Thank you Mr. Chair first of all a comment please sir I think that this presentations are very valuable because for me knowing where the issues are and where the holes are very important in our getting into the bottom of all of this so I thank you very much. I do have a question it relates to slide number 9 the investment that we are making in these low birth weight babies is staggering I mean it is an awful a lot of money and one other things that has come to my attention that I'd like to have verified at somepoint is that while we invest this large sums of money in the very early days of a child I'm hearing reports [xx] that the end of support trails off post natal and so I think for an outcome situation were not talking about just a birth situation but if we re going to as a society invest this kind of dollars in the early days we need to make sure those investments count by continuing to support this families and this children in a cost effective manner and so in the future I would like see more data about that as well. Okay thank you mum I do thank the department, the chief medical officer for medicaid mentioned the fact that there is some follow up in lactation and other things that are there. I think the health departments are really on the front line for all of this, at least my health director talks to me about it and the counties there on a bron[sp?] of it. No other questions, may I ask a question please, yesterday I was involved in two discussion and this relates somewhat to what we're talking about today. Its my understanding that in 31 counties in North Carolina we have no OBGYN docks present. Does anybody know that answer? I've not seen information, I'm not sure if the department has any information to answer that. Thank you Mr. Chairman, I don't have the commotion on the exact number of counties but I would clarify that not having an OBGYN doctor does not mean that there are no delivery services in those counties. So we will need to know if take them with positions after running delivery services. Okay, well, the reason I ask is the fact that there is a

bill about having certified nurse/midwives, not being under the scrape of or supervision of OBGYN docs, we got into discussion yesterday where couples folks about it that I'm just trying to discern if we did not have to allow certified nurse/midwives in those counties would there be more of those in those undeserved counties. I would suppose that the only thing left in those counties that are unreserved, we know OBGYN doc is a massive run and I don't think probably that's a factory other than public health folks that are around the front lines again so, it's to my understanding that South Carolina has approved a bill that parallels this which someone would share with me whether or not in the under served counties in South Carolina once the bill was passed, and the certified nurse/midwives could practice without the supervision of ugly GY and dark, if they provided or migrated to those poor counties to offer those services, and you can make living off Medicaid payments. Just if someone would share that with me as we move through this process, the bill is not going [xx] but it would be helpful if I had that factual data that compares between the two states. It's my understanding we're more restrictive in certified nurse/midwives and birth rates as a state. So, that's kind of thing I'm looking for, is poor counties being served by somebody either in emergency room or public health? And public health may be doing adequate job but I'll lay your odds, some of those counties so children are not making it or their primes or their undeserved, so I just need  just some clarification on that if you would, any other question? Any other questions? 9.35, there's no other questions there's no other items on the agenda, this meeting is adjourned.