Last July, North Carolina launched what NC DHHS termed “Medicaid Transformation.” This included the transition of the state’s Medicaid program to Managed Care, where the payment and administration of (most) Medicaid services is now delegated to private Prepaid Health Plans. This transition to managed care was long anticipated and has been the subject of a great deal of national attention as an example of the state as a “laboratory for innovation” for Medicaid policy and design.
We are now many months into Medicaid Transformation, and with the first frenetic months of implementation behind us, it is worth stepping back and reviewing Medicaid Transformation as a whole. While Transformation has brought about significant changes to North Carolina’s Medicaid program, it is important to understand that, by and large, when it comes to most of the program’s design and delivery it is not particularly innovative. Instead, the model represents an iteration of existing payment and administration models. For example, administration of Medicaid by managed care organizations has been done in other states dating back almost 40 years. Similarly, the Advanced Medical Home model is an iteration of the long-implemented patient centered medical home.
Introducing the Healthy Opportunities Pilot
So why are so many eyes on North Carolina’s Medicaid Transformation? It’s because North Carolina is the first state to test the impact of assessing and addressing non-medical needs on the cost and quality of health care for Medicaid beneficiaries. And this is a big deal and represents an example of innovation. Specifically, through an 1115 Medicaid demonstration waiver, the federal government authorized North Carolina to use $650 million in Medicaid funding to implement Healthy Opportunities pilots in 3 locations in the state to focus on four health-related resource needs:
- Food insecurity
- Housing Insecurity
- Interpersonal Safety
Those of us that work in healthcare are all too familiar with the statistic that 80% of a person’s health is determined by non-healthcare factors, including social and environmental factors. For example, someone who has diabetes and obesity, low-income, and lives in a food desert
will struggle with controlling their diabetes because they do not have access to healthy food. On the same hand, if someone lacks transportation, how are they supposed to get to doctor’s appointments, to a pharmacy to pick up medication, or to a grocery store?
Attention to non-medical needs (commonly known as social determinants of health) is not entirely new. What is new is that North Carolina has made significant investments in creating the needed support infrastructure to support the Healthy Opportunities pilots
, as well as inform and drive community investments in addressing health-related resource needs. This includes creating an interactive map
that is organized by region (Wilmington is located in Region 8) that shows, among other things, housing and transportation conditions. This is a powerful tool for policy makers at the state and local level, for community-based nonprofits striving to serve their communities, as well as healthcare providers and organizations that provide care and treatment to the members of the community. For example, nonprofit hospitals have an obligation to make investments in their communities. This tool can help inform and reinforce those investments.
Health Screening Tools: Closing Loops between Social Support and Medical Services
Additionally, NC Department of Health and Human Services (NC DHHS), the department with oversight of Medicaid, underwent an intensive evidence and research-based process over multiple years, to develop and test a standardized screening tool
that providers, health plans, and care managers can use to identify patients that have health-related resource needs. My colleague, Sarah Jagger, discusses
the vital importance of providers engaging with their patients on the social needs in establishing a foundation of trust that is necessary to the patient-provider relationship. While a provider may not conduct these screenings directly, they do have access to the results. Having a standardized, reliable screening tool is an important first step in engaging patients on these issues
Many providers have expressed concern about asking patients if they have such needs and then not having a means of providing them resources to addresses those needs. Health care providers aren’t known for being comfortable knowing about a problem and not being able to do something about it. To help with this dilemma, NC DHHS and the Foundation for Health Leadership and Innovation, in a public-private partnership, established NCCARE360
. This is the first statewide electronic network of community-based organizations providing services and supports to people with health-related resource needs. Now, if a patient is identified with housing needs, as an example, the patient and a member of their care team can utilize this online resource to find an organization that can provide support, make a real-time referral to the organization, and the organization can accept the referral and ensure that the loop is closed, ending in the patient obtaining the needed service or support.
These tools on their own are significant and each reflect important steps forward in addressing the social and environmental factors that influence people’s health and wellbeing. But NC DHHS has taken things one step further. Through the Healthy Opportunity Pilots
, North Carolina will invest $650 million to establish and evaluate a “systematic approach to integrating and financing evidence-based, non-medical services into the delivery of healthcare.” If successful, this model will be rolled out statewide.
A Home Site to the Healthy Opportunity Pilot
In the greater Cape Fear region, we are lucky to be one of the pilot sites. CCLCF, Inc
., in partnership with Cape Fear Collective, UNCW, and Novant NHRMC, was selected as the Healthy Opportunity Pilot Network Lead to serve Bladen, Brunswick, Columbus, New Hanover, Onslow, and Pender Counties by establishing a network of Human Services Organizations. Through the pilot, Human Services Organizations (HSO) will receive payment for 29 services
across the NC DHHS’ four priority areas: food, housing, transportation, and interpersonal safety. This pilot will bring an infusion of more than $7 million into our communities. In addition, the Network Lead will provide invaluable support including data analytics and training to build the sustainability of these vital community organizations.
Much work has been going on behind the scenes over the last six months to prepare for the launch of HOP. Throughout this process, NC DHHS and the stakeholders, including the Medicaid health plans, providers, Network Leads, and others, have realized the need to roll this out slowly and intentionally. This means that services will roll out over a period of a few months:
- Food Services: March 15, 2022
- Housing and Transportation Services: May 1, 2022
- Interpersonal Safety and Cross-Domain Services: June 15, 2022
To qualify for services through the pilot, a Medicaid enrollee must have one qualifying physical or behavioral health condition and at least one qualifying social risk factor. The Medicaid PHPs are responsible for managing and maintaining the HOP enrollment process. At Atromitos, we question whether this is the best approach and anticipate that over the course of the pilot, this will be an important point of evaluation and learning.
Advanced Medical Homes (AMH) play an important role in screening and identifying patients that are eligible for HOP and ensuring they are connected to a HSO in their community. This program is being implemented less than a year after the implementation of managed care and the AMH model of care delivery. This will require amendments to existing payer-provider contracts in the geographic regions where the pilots will occur. It will also require changes in workflows for providers. There is an important opportunity for NC DHHS to provide support and education to AMHs at the beginning and throughout the pilot to ensure its success.
Finally, the Network Leads and HSOs have a lot of work to do to get ready and then to successfully carry out this incredible opportunity. Network Leads will play a critical not only in creating the network of HSOs but providing the necessary training and resources to HSOs so that they can evolve and grow into sophisticated organizations that can be sustained over time.
Next Steps and Looking Forward
There is a lot of risk in this pilot, as is always the case with true innovation, but there is also incredible opportunity to make a meaningful and significant impact on individual lives and entire communities.
At Atromitos, we are grateful that we work with key stakeholders in the area implementing this incredible program. It aligns perfectly with our company mission of creating healthier, more resilient, and more equitable communities. We call on our fellow community stakeholders to learn more about this innovation and find ways to support and encourage its success, so that we can spread this across North Carolina!
Michealle Gady, JD, is Founder and President of Atromitos, LLC, a boutique consulting firm headquartered in Wilmington, North Carolina. Atromitos works with a variety of organizations from health payers and technology companies, to community-based organizations and nonprofits but their work reflects a singular mission: creating healthier, more resilient, and more equitable communities. Michealle takes nearly 20 years’ experience in health law and policy, program design and implementation, value-based care, and change management and puts it to work for Atromitos’ partners who are trying to succeed during this time of dramatic transformation within the U.S. healthcare system. Outside of leading the Atromitos team, Michealle serves as a Board Member for both the Cape Fear Literacy Council and A Safe Place and is a member of the American College of Healthcare Executives and American Health Law Association.