Three North Carolina Pilots Say Everything We Need to Know about Medicaid’s Future

June 17, 2021
The North Carolina Department of Health and Human Services’ announcement Tuesday that it was launching three SDOH-related pilot programs in rural parts of the state points to tremendous potential in the future

As Senior Contributing Editor David Raths wrote on June 15, “The North Carolina Department of Health and Human Services has selected three regions of the state to pilot a systematic approach to integrating and financing non-medical services that address housing stability, transportation access, food security and interpersonal safety into the delivery of healthcare for Medicaid beneficiaries. On July 1, North Carolina will launch a major transition to Medicaid managed care, which will impact how millions of North Carolinians receive care. Among the goals are improving access to preventive health and wellness programs and driving down long-term healthcare costs.”

Further, he wrote, “The state said the regional pilot projects will mark the nation’s first comprehensive program to test evidence-based, non-medical interventions designed to reduce costs and improve the health of Medicaid beneficiaries.” What North Carolina’s DHHS leaders have done is to launch three pilots covering three regions. They are as follows: Access East Inc. (in Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, and Pitt counties); Community Care of the Lower Cape Fear (in Bladen, Brunswick, Columbus, New Hanover, Onslow, and Pender counties); and Dogwood Health Trust (in Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, and Yancey counties).

As Raths noted, “The Centers for Medicare and Medicaid Services (CMS) approved the Healthy Opportunities Pilots in 2018 as part of the state’s waiver to transition to Medicaid managed care.   "The Healthy Opportunities Pilot will integrate the services that address these non-medical drivers of health and build the evidence base to identify which services are most effective at improving a person’s health and lowering their health care costs, said DHHS Secretary Mandy K. Cohen, M.D., in a statement. To be eligible for and receive pilot services, NC Medicaid Managed Care members must live in one of the three selected regions, have at least one qualifying physical or behavioral health condition, and have one qualifying social risk factor.” And he noted that “The federal government has authorized up to $650 million in Medicaid funding for the pilots, which will cover the cost of delivering the non-medical services and, in the first two years, support capacity building for human service organizations needed to effectively deliver non-medical services in a health care context.”

In a May 27 press release, the North Carolina DHHS provided more details about the initiative on its website. It quoted DHHS Secretary Mandy K. Cohen, M.D., as stating that "North Carolina continues to lead in innovative approaches to build a well-coordinated system of care that addresses both the medical and non-medical drivers of health. The Healthy Opportunities Pilot will integrate the services that address these non-medical drivers of health and build the evidence base to identify which services are most effective at improving a person’s health and lowering their health care costs."

As the press release noted, “To be eligible for and receive pilot services, NC Medicaid Managed Care members must live in one of the three selected regions, have at least one qualifying physical or behavioral health condition, and have one qualifying social risk factor.” Further, “The federal government has authorized up to $650 million in Medicaid funding for the pilots, which will cover the cost of delivering the non-medical services and, in the first two years, support capacity building for Human Service Organizations needed to effectively deliver non-medical services in a health care context. The department will work with the Healthy Opportunities Network Leads (formerly referred to as Lead Pilot Entities), Prepaid Health Plans (PHPs), care management entities and Human Service Organizations to implement the pilot program. Human Service Organizations are community-based organizations and social services agencies that will deliver pilot services and be overseen by Healthy Opportunities Network Leads.”

The NCDHHS stated the following goals for the pilots, as follows:

Ø Evaluate the effectiveness of select, evidence-based, non-medical interventions and the role of the Network Leads in improving health outcomes and reducing health care costs for high-risk NC Medicaid Managed Care members.

Ø  Leverage evaluation findings to embed cost-effective interventions that improve health outcomes into the Medicaid program statewide, furthering the department’s goals for a sustainable Medicaid program.

Ø  Support the sustainability of delivering non-medical services identified as effective through the evaluation, including by strengthening the capabilities of Human Service Organizations and partnerships with health care payers and providers.

So, here’s what’s exciting about all of this. North Carolina was one of the last states to plunge full-bore into Medicaid managed care; indeed, it’s long been noted that North Carolina is the last of the largest states by population to move forward to transform its Medicaid program into a managed care program. But these goals reflect a very advanced understanding of the social determinants of health (SDOH), and the potential for Medicaid leaders to better collaborate with community social service agencies.

What’s more, North Carolina is a relatively poor Southern state, with more than 288,000 residents enrolled in Medicaid, and fully 14.9 percent of its residents currently enrolled in either Medicaid or CHIP, the Children’s Health Insurance Program.

And these innovations embedded in the list of goals for the pilots are very clear-eyed and quite laudable.

Not surprisingly, Mandy K. Cohen, M.D., the NCDHHS Secretary, has been leading this set of innovations. Dr. Cohen, who has garnered great respect for her healthcare policy leadership in North Carolina. Indeed, in December of last year, the Raleigh News & Observer named her “Tar Heel of the Year.” On Dec. 23, the Observer’s Andrew Carter wrote that “Cohen is The News & Observer’s 2020 Tar Heel of the Year, an honor that recognizes a North Carolina resident who has made lasting and significant contributions in the state and beyond,” for her leadership during the COVID-19 pandemic. “In the longest of years, one defined by the pandemic and by how world leaders and common citizens have responded to it,” Carter wrote, “Cohen has become the figurative and literal face of North Carolina’s ongoing fight against COVID-19. It is a fight in which she’s relied most upon data and science and something less easily quantified: the sense of empathy and compassion that some closest to her say make her a perfect fit for her position. It is a fight that’s challenged her to balance competing interests — one that at times has brought fierce criticism from skeptics who dismiss science or downplay the virus — while maintaining the goal of preserving the health and lives of North Carolinians.”

And, as Greensboro CBS affiliate WFMY News 2’s Ben Smart noted on November 8 of last year, “Dr. Mandy Cohen, secretary of the North Carolina Department of Health and Human Services, is among the top contenders to lead the incoming Biden administration's U.S. Department of Health and Human Services, according to new reporting from POLITICO. The New York native has experience in medicine, advocacy, and government, and also became a household name in North Carolina for her work during the COVID-19 pandemic. A man in Burlington even wrote her a tribute song.”

It is precisely her innovative approach to healthcare policy that made Cohen reportedly one of the individuals considered either for the Health and Human Services Secretary or Administrator of the Centers for Medicare & Medicaid Services posts, though ultimately, former California Attorney General Xavier Becerra and former Manatt senior consultant Chiquita Brooks-LaSure ended up being chosen for those posts.

But Cohen’s innovative approach to her job will most certainly be of substantial help in this broad initiative. What’s more, much of the geography covered by these three pilots is rural or semi-rural, and the Medicaid enrollees targeted for service are the highest-risk Medicaid enrollees. So this initiative is perfectly targeted. And as I’ve been saying for a very long time already, Medicaid managed care is the perfect laboratory for innovation around care management in the U.S. healthcare system: if care and case managers in Medicaid can improve health status for those in the program at highest risk, the entire U.S. healthcare system can do so.

So the next few years will be a period of tremendous potential for North Carolina Medicaid. We all need to keep an eye out for progress in this innovative program; the learnings from this program could point the way to opportunities across the entire U.S. healthcare system.

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