Managing health disparities across North Carolina

Community Care of North Carolina Early Adopter of Population Health Approach
Aug 12, 2014

RALEIGH, N.C. (August 12, 2014) “Population health” is a term used frequently in Medicaid discussions across the nation. States look to this approach to guide efforts to improve the quality of care provided to Medicaid patients while controlling increasing healthcare costs.


Population health focuses on the well-being of a defined group of people, rather than the one-patient-at-a-time approach of traditional medicine. It aims to improve the health of an entire population set by identifying and addressing health disparities that arise from the complex factors that determine health. Populations can be employee groups, geographic regions, or, in the case of Medicaid, a group of individuals eligible for a specific government health program. While the mix is different for each population, health is influenced by complex, interrelated factors such as living and working conditions, poverty, and genetic predisposition to specific diseases.  Population health managers analyze data to help prioritize health problems in the population and efficiently allocate resources available to help patients.

Community Care of North Carolina (CCNC), the nonprofit organization that manages the utilization of North Carolina’s Medicaid program, has employed a population health approach since its inception in the late 1990s and continues to emphasize the concept today.


“CCNC was one of the first organizations to implement population health programs on a statewide scale,” said L. Allen Dobson, Jr., MD, CEO of CCNC. “Population health is a ‘big picture’ orientation that allows us to allocate resources in an optimal way for our particular population. It helps us find gaps in care and opportunities to intervene at key points in the care process that produce better outcomes for patients.” 

“We can see, for example, that diabetics in a particular region are doing better or worse than the average and can ensure that they are getting the care they need in real-world settings. Population health helps us see that often the patients who aren’t coming in for care need help as much or more than those who are. For example, a diabetic who hasn’t had his blood sugar measured in over a year is very likely to have problems if this screening is not arranged promptly. CCNC is about empowering primary care physicians to improve care by proactively seeking out and screening such patients.”


CCNC’s population management approach includes evidence-based programs to engage patients, real-time data provided at the point-of-care, programs aimed at chronic diseases prevalent in its population, and local care managers across the state, many embedded in hospitals and medical practices.

“Population health considers the risk factors that cause poor health outcomes in our patients and helps us identify clinical interventions that lead to better health outcomes for our population,” said Dr. Tom Wroth, a family medicine physician. “Over time, this data-driven approach leads not only to better health for our enrollees but also a lower cost per Medicaid member. Getting better outcomes at lower cost for Medicaid is a win both for patients and for the taxpayer.”

CCNC’s population health management approach and award-winning care model saved the state of North Carolina an estimated $1 billion over four years. By continuing to execute population-based health management initiatives, CCNC is working toward a healthier North Carolina and a healthier nation.

Comments (5)
Posted by: Jim Bothwell | Aug 13, 2014 10:55

Excellent article.

“Over time, this data-driven approach leads not only to better health for our enrollees but also a lower cost per Medicaid member. Getting better outcomes at lower cost for Medicaid is a win both for patients and for the taxpayer.”

For anyone vaguely interested in the history of this approach may I suggest reading the information about W. Edwards Deming;

The Deming statistical approach is used in a variety of fields to accomplish quality improvement in products, performance, agencies, departments, governments, etc.  The CCNC use of the Deming method is merely another example of how good the Deming method remains to this day.

Jim Bothwell

Posted by: Scott Lilly | Aug 13, 2014 11:50

Well and good.  But when it comes to MY health and MY body and someone (a medical doctor) I consult, it ought to be MY decision and nobody else's.  And I should be expected to take full responsibility for MY decision about MY health and MY body.  That means I am responsible for the costs, the pain, the effort, the risks, and any results.  As our society starts to empower others to decide our healthcare for us, these statistical management entities will be more important.


I'm not sure how I would react to this: "CCNC is about empowering primary care physicians to improve care by proactively seeking out and screening such patients."  So the government now has (will have?) a right or duty to go find people to treat however they think is appropriate?  If a public servant knocked on my door to tell me that it's time to collect my blood (so says the government), I might not react too kindly to that.


I'm sure this nonprofit has lots of reason to ask for public money.  And I'm sure they want to do good.  But I don't like the concept behind it.  It is inconsistent with the freedom I'm supposed to have and the government's duty to protect my freedom.

Posted by: Scott Lilly | Aug 13, 2014 12:01

Another case in point.


Each year I am REQUIRED by law to have my car inspected.  And I just love it when they find that I need a $1,500 catalytic converter and then later realize that I really only needed a $150 oxygen sensor and only learned that after replacing a $200 Mass Airflow Sensor.  And my car still puts out the same exhaust before I spent the $1,850.


How long will it take until we all are REQUIRED to get an annual physical if this entity is "proactively seeking out and screening patients?"  I already have private insurance that gives me a discount if I voluntarily get a physical and maintain a "healthy lifestyle".  If they check my blood during one of these physicals and someone says my cholesterol is too high, who's going to then tell me that I have to take a medication or else pay a penalty?  What happens if I decide not to have my car inspected?  What happens if I fail my inspection and choose not to make a required repair?  Is this where we want to go as a society with our healthcare?

Posted by: Charles Zimmerman | Aug 13, 2014 13:23

          Anyone choosing not to have health coverage most certainly can It is they and only they who. along with their doctor, chose what care is given. All others having paid for insurance coverage are limited by what the insurance provider deems necessary. And yes, insurance companies will pull the plug on their insures. Make no mistake about it. Insurance companies will sometimes not approve certain procedures also medications. This is true with Obamanater-care as well. It is not a government agency nor person who makes the decision. It is the insurance company.

               Most certainly We the people may require all to be insured or pay a penalty. Just like with auto insurance. It is in the best interests of US.

                If you have a vehicle that has a CEL(check engine light) or otherwise has too many fault codes, depending on age, it will fail N.C. inspection. If you have spent at least $200.00 to fix it and it still won't pass, you may go to DMV and talk to a N.C. vehicle inspector whose office is on the right and they will give you an exemption. I have this with a 2001 Subaru we bought new. 1998-2001's computers were very finicky. There are many others who also cannot pass for various reasons. In fact there are certain cars that when they are plugged into inspectors computer, come with a inspection not required or something like that whereby the state recognized they cannot pass and are given a free pass. Certain Volvos are like that. I have heard tell of many a person spending thousands of bucks and still not passing. Don't buy factory cat, unless you have to. There are several very good reputable companies making 50 state cats. Make sure the cat is good for 50 states. The 48 state cats are of lesser value. My mistake was I replaced exhaust system with a high-flow, cat included. It has too little backpressure at end of cat. I plan on making a reducer to fix it. I hope. It is down the list of other projects right now.

              Pass the advice about the exemption along to anyone that needs it.  Many don't. It at least gives a year to fix the problem or trade it.



Posted by: Scott Lilly | Aug 13, 2014 13:31

Mr. Zimmerman, I am going to take your CEL advice.  I've got $3,000 invested already and the CEL is STILL on!  The car is 14 year old and has 191k on it.  Otherwise runs and looks great.  Thanks for the tip!

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