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.