North Carolina pioneered patient-centered medical homes and other ways to manage health care for Medicaid recipients. But it was one of the last states to contract with managed care organizations and did not expand Medicaid.
When it comes to enrolling Medicaid members in managed care, North Carolina is both an innovator and an outlier.
The state has been an innovator since the 1980s, when it began using different forms of managed care for Medicaid recipients, including primary care case management and patient-centered medical homes. But North Carolina is also on the fringes because it’s one of 12 states that has yet to expand Medicaid enrollment under the Affordable Care Act (ACA) and, until last year it was one of 10 states not to have a contract with a private party. company to manage the health care of its Medicaid beneficiaries.
But on July 1, 2021, North Carolina launched its Medicaid Transformation program to enroll 1.7 million Medicaid beneficiaries in five for-profit managed care organizations (MCOs) – AmeriHealth, Blue Cross Blue Shield, Carolina Complete Health, UnitedHealthcare and WellCare – or in a healthcare program for members of the Eastern Band of Cherokee Indians. Seven months later, North Carolina Health News, a news website, reported that the move to OLS had resulted in hundreds of complaints to state officials. When the program started, about 25% of Medicaid recipients were unaware and as of February, thousands of people were still confused based on reports filed with the state Medicaid Ombudsman’s office, reported the news site.
“As with any new program, there’s always a learning curve and issues to deal with,” says Rebecca Whitaker, Ph.D., director of research at the Duke-Margolis Center for Health Policy in Durham, North Carolina. . “But people are working together to make sure these issues don’t prevent people from accessing the care they need.”
A March 2022 survey conducted by North Carolina for Better Medicaid, a coalition of patient advocates, community groups and health plans, showed the transition to managed care was not a disaster, as some l predicted, nor the panacea that many wanted.
Meanwhile, about 1.1 million Medicaid-eligible adult residents in North Carolina remain uncovered because the state has not expanded Medicaid. Christopher A. Cooper, Ph.D., professor and director of the Public Policy Institute at Western Carolina University, says tightly divided partisan politics is one reason North Carolina has, in some ways, been in delay on Medicaid policies. “There’s no way to have a conversation about health policy without talking about politics,” he says. “We’re a purple state, with a Democratic governor and a Republican legislature, which means we’ve been a little slower moving forward on a variety of health policy issues.”
Pioneer Tar Heel
Yet North Carolina can claim one of the most innovative Medicaid programs in the country in terms of health care delivery and addressing the social determinants of health. As
Politico reported that in 1989 the state developed a home medical care and case management program for low-income people under a program known as Carolina Access. Primary Care Case Management (PCCM) programs are among the oldest types of Medicaid managed care and often lead states to have managed care organizations provide care to Medicaid members, according to a report. from the National Academy of State Health Policy last year.
When Carolina Access began, it was a physician-led PCCM program for Medicaid recipients in 12 of the state’s 100 counties. Participating physicians received $3 per member per month to provide care and coordinate member care with other providers and authorize specialist referrals as needed. In 1992, state officials agreed to expand the program statewide, and by the end of 1997 it was operating in all but one of North Carolina’s 100 counties; Mecklenburg County, where Charlotte is located, was the exception.
At that time, the program had more than 2,000 primary care physicians operating medical homes for more than 650,000 Medicaid members, approximately 70% of whom were women and children. One of the goals of medical homes is to reduce non-emergency visits to the emergency room, one of the most expensive places for care. The program reduced those visits by 30%, according to Community Care of North Carolina (CCNC), a public-private partnership of regional networks of primary care clinicians, hospitals, pharmacies, public health agencies and other groups.
By 2001, CCNC had become the successor to Carolina Access. Under the CCNC, physicians participating in statewide provider-led networks received payment per member per month not only to provide primary care services, but also to coordinate care for recipients, says Whitaker. These providers work in multidisciplinary teams to provide routine care – and still do today – and provide complex and expensive care to beneficiaries with chronic conditions, such as diabetes.
“Through this program, the state has had great success and received some national recognition for this initiative,” Whitaker said.
For Whitaker, three of North Carolina’s Medicaid program innovations stand out. First, the program adopted value-based compensation for providers who coordinate care to improve patient outcomes. Second, it integrates behavioral and physical care with pharmacy services. And third, the program addresses the social drivers of health care costs and outcomes. Community organizations are reimbursed with Medicaid dollars to provide 29 services at a fee schedule that are related to factors such as lack of housing, food, or transportation, or that are related to interpersonal violence and toxic stress, said Whitaker.
A big question remains, says Cooper. Will North Carolina expand Medicaid? Yes certainly seemed like the answer, but in August a carefully brokered deal fell apart at the last minute.
Cooper says there are good reasons for North Carolina to move forward with Medicaid expansion. He would get increased funding and potentially a better return on his investment in managed care. “The ROI argument is compelling, and also, the sky hasn’t fallen since the Medicaid transformation began,” he says.
The Republican-led Senate voted 44-2 to expand Medicaid in June. One reason for the vote was testimony showing the federal government would provide $1.5 billion under the American Rescue Plan Act of 2021 to help pay for the 10% share of Medicaid expansion costs. of that state to cover those who are uninsured. These costs are estimated at around $8 billion per year. These federal funds would cover the remaining 90%. Democratic Gov. Roy Cooper has long been a supporter of Medicaid expansion, and he repeated that in July.
State Sen. Kevin Corbin (R-Franklin) agrees. Corbin has first-hand experience of the extent to which Medicaid expansion would benefit the state’s low-income residents. In addition to his work in the state Senate, Corbin is an insurance broker who helps low-income residents obtain health coverage.
“Take the example of a single mother who has two children and earns a living wage working 30 hours a week at around $14 an hour,” he says. “That’s less than 100% of the federal poverty level, which means she doesn’t qualify for tax credits under the Affordable Care Act.”
There was no way she could afford the standard $650-a-month health insurance policy, Corbin believes. Earning too much to qualify for Medicaid and too little to qualify for ACA grants, she falls into the Medicaid coverage gap. That means she is uninsured while her children are eligible for coverage under the Children’s Health Insurance Program, he says.
When this mother needs health care, she is unlikely to have a primary care physician and therefore may seek care in the emergency department. If she is unable to pay, North Carolina taxpayers would cover those costs, he says.
Joseph Burns is a freelance journalist in Brewster, Massachusetts, covering health care, health policy and health insurance.
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