NC’s Medicaid Transformation: Between Iteration And Innovation by Michealle Gady

Last July, North Carolina launched what NC DHHS called the “Medicaid Transformation”. This included the transition of the state Medicaid program to Managed Care, where payment and administration (most) of Medicaid services are now delegated to private prepaid health plans. This transition to managed care has long been anticipated and has become the subject of much attention of the country as an example of the state as an “innovation laboratory” for Medicaid policy and design.

We have now spent many months in the transformation of Medicaid, and if the first crazy months of implementation are behind us, we should step back and reconsider the Transformation of Medicaid as a whole. While Transformation has brought significant changes to the North Carolina Medicaid program, it’s important to understand that in general, when it comes to most of the program’s development and delivery, this is not the case. in particular innovative. Instead, the model represents iteration existing payment and administration models. For example, Medicaid managed care organizations were managed in other states nearly 40 years ago. Similarly, the Advanced Medical Home model is an iteration of a long-implemented patient-centered medical home.

Introducing the Healthy Opportunities pilot program

So why so many eyes on the transformation of Medicaid North Carolina? This because North Carolina is the first state to test the impact of assessing and meeting non-medical needs on the cost and quality of care for Medicaid beneficiaries. And this there is big deal and is an example of innovation. In particular, by refusing to demonstrate Medicaid 1115, the federal government allowed North Carolina to use $ 650 million in Medicaid funding to implement Healthy Opportunities pilot programs in 3 state locations to focus on four health-related resource needs:


  • Food security
  • Housing insecurity
  • Transport
  • Interpersonal security

Those of us who work in health care are all too familiar with the statistic that 80% of human health is determined by factors that are not medical, including social and environmental factors. For example, a person with diabetes and obesity, low-income and living in the food desert will struggle with controlling their diabetes because they do not have access to healthy food. In the same direction, if someone lacks transport, how to get to the doctor, to the pharmacy to pick up medicine, or to the grocery store?

Attention to non-medical needs (commonly known as social determinants of health) is not entirely new. What’s new is this North Carolina has made significant investments in building the necessary support infrastructure to support Healthy Opportunities pilotsas well as informing and stimulating community investment in addressing health-related resource needs. This includes the creation of an interactive map organized by region (Wilmington is in Region 8), which shows, among other things, housing and transport conditions. It is a powerful tool for policymakers at the state and local levels, for community-based nonprofits seeking to serve their communities, and for health care providers and organizations that provide care and treatment to community members. For example, nonprofit hospitals are required to invest in their communities. This tool can help inform and enhance these investments.

Health screening tools: closing cycles between social support and health services

In addition, the NC Department of Health and Human Services (NC DHHS), the department overseeing Medicaid, has for several years conducted an intensive evidence-based and research-based process to develop and test a standardized survey tool for providers, health plans and assistance. managers can use to identify patients who need health-related resources. My colleague, Sarah Jagger, discusses the vital importance of providers interacting with their patients on social needs in building the foundation of trust needed for a patient-provider relationship. Although the provider may not conduct these checks directly, they have access to the results. Having a standardized, reliable survey tool is an important first step in engaging patients with these issues..

Many providers have expressed concerns about patients ’needs, and then not having the means to provide them with the resources to meet those needs. Healthcare providers are not known to be comfortable knowing about a problem and cannot do anything about it. To help with this dilemma, NC DHHS and the Foundation for Health Leadership and Innovation in a public-private partnership created NCCARE360. It is the first nationwide electronic network of community-based organizations that provide services and support to people with health-related resource needs. Now that the patient is identified with housing needs, for example, the patient and a member of their care team can use this online resource to find an organization that can provide support, refer the organization in real time and the organization can take referral and make sure the cycle closes, causing the patient to receive the necessary service or support.

These tools are important in their own right, and each reflects important steps forward in tackling the social and environmental factors that affect people’s health and well-being. But NC DHHS took it one step further. As part of the Healthy Opportunity Pilots, North Carolina will invest $ 650 million in developing and evaluating “a systematic approach to integrating and funding evidence-based non-medical services into health care”. If successful, this model will be deployed nationwide.

Home site for the Healthy Opportunity pilot program

In the large Cape Fir region we were lucky to be one of the pilot sites. CCLCF, Inc., in partnership with Cape Fear Collective, UNCW and Novant NHRMC, has been selected as head of the Healthy Opportunity pilot network to serve Blayden, Brunswick, Columbus, New Hanover, Onslow and Pender counties by building the Social Services Network. As part of the pilot program, social services organizations (HSOs) will receive payment for 29 services in four priority areas of NC DHHS: food, housing, transportation and security between people. This pilot will bring more than $ 7 million to our communities. In addition, the network manager will provide invaluable support, including data analytics and training, to build the sustainability of these vital community organizations.

Over the past six months, a lot of work has been done to prepare for the launch of HOP. During this process, NC DHHS and stakeholders, including Medicaid health plans, vendors, network managers and others, realized the need to slowly and deliberately disseminate this. This means that the services will be deployed in a few months:


  • Meals: March 15, 2022
  • Housing and transport services: May 1, 2022
  • Interpersonal Security and Inter – Exchange Services: June 15, 2022

To qualify for services through a pilot, a Medicaid entrant must have one physical or behavioral health condition and at least one qualified social risk factor. PHP Medicaid PHPs are responsible for managing and maintaining the HOP registration process. At Atromitos, we question whether this is the best approach, and believe that during the pilot project it will be an important point of evaluation and learning.

Advanced Medical Homes (AMH) play an important role in screening and identifying patients eligible for HOP, and in ensuring their connection to HSO in their locality. This program is being implemented less than a year after the introduction of managed care and the AMG care model. This will require changes to existing payer and supplier contracts in the geographical regions where the pilot activities will take place. It will also require changes in workflows for vendors. For NC DHHS there is an important opportunity to support and educate AMH at the beginning and throughout the pilot project to ensure its success.

Finally, network and HSO executives need a lot of work to prepare for and then successfully realize this incredible opportunity. Network leaders will play a crucial role not only in building the HSO network, but also in providing the HSO with the necessary training and resources so that they can evolve and evolve into complex organizations that can be maintained over time.

Next steps and look forward to

There is a great risk in this pilot project, as is always the case with real innovation, but there is also an incredible opportunity to have a significant and significant impact on the lives of individuals and communities.

At Atromitos, we are grateful to be working with key stakeholders in the field to implement this incredible program. This is in line with our company’s mission to create a healthier, more sustainable and fairer community. We encourage our fellow stakeholders in the community to learn more about this innovation and find ways to support and encourage its success so that we can spread it throughout North Carolina!

Michael Gaddy, JD, is the founder and president of Atromitos, LLC, a boutique consulting firm headquartered in Wilmington, North Carolina. Atromitos works with a variety of organizations, from health care payers and technology companies to community and nonprofit organizations, but their work reflects a common mission: to create a healthier, more sustainable, and fairer community. Michealle has nearly 20 years of experience in health legislation and policy, program development and implementation, value-based care and change management, and makes it work for Atromitos partners who are trying to succeed in this time of dramatic transformation in US health care system. In addition to leading the Atromitos team, Michal is a member of the Cape of Fear and Safe Place Literacy Council, and is a member of the American College of Health Care Managers and the American Health Law Association.

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