Evaluating North Carolina's Medicaid transformation to managed care, focusing on improved health outcomes and addressing social determinants of health.
State Medicaid policies have been critical in bringing health care coverage to thousands of people in North Carolina who have low incomes, manage specific health conditions or disabilities, or need long-term care.
Now, thanks to recent state legislation, N.C. has become one of the first states in the southeast to expand Medicaid coverage to thousands more. The N.C. Department of Health and Human Services (NC DHHS) has embarked on a multifaceted effort to transform how providers receive payment for that care, and they tapped the UNC Gillings School of Global Public Health to serve as the project’s official independent evaluator.
The project is one of many that have developed thanks to years of partnership and data-sharing between UNC-Chapel Hill and NC DHHS, according to Mark Holmes, PhD, professor of health policy and management at the Gillings School and director of the Cecil G. Sheps Center for Health Services Research.
“The partnership is a strategic benefit for everyone,” he said, “and it allows us to weigh in on the things that matter to the people of N.C. The Gillings School is providing expertise to DHHS that enables the evaluation, with involvement from other UNC partners in the Schools of Medicine, Social Work and Pharmacy.”
"This partnership with the state exemplifies the commitment of the Gillings School to improve public health by bridging research and real-world application. Faculty are using their expertise to help drive positive change for the people of N.C. through evidence-informed policy decisions."
Enacted based on policy from the N.C. General Assembly (NCGA) in 2015, the overall aim was to move health care providers participating in Medicaid from a model where they are paid per office visit (called “fee-for-service”) to one where providers are paid based on the improved health outcomes of their patients. Called “managed care,” this approach incentivizes the increased use of health-improvement measures, screenings and tools to keep patients well.
As part of this process, N.C. Medicaid has contracted with third-party insurance providers, such as AmeriHealth Caritas, Blue Cross and Blue Shield, and UnitedHealthcare, who will offer pre-paid managed care health plans to Medicaid participants. These participants will then receive care through a network of doctors contracted to provide services through these managed care organizations (MCOs).
Under the guidance of federal rules, each state has control over the administration of its own Medicaid program, and nearly all of them have adopted some form of MCO system. N.C. was one of the last states to adopt the Medicaid MCO model, and according to a 2023 report from KFF, Alaska and Wyoming remain the only states without one.
The Centers for Medicare & Medicaid Services (CMS) require an external evaluator to ensure the transformation is accomplishing the goals it set out, and so the UNC-led evaluation is examining the process through four workstreams. The first is through evaluating administrative data to see what kind of trends reflect the impact of the transformation. The second is through provider surveys that seek to understand the experiences of health care professionals during the process, and the third is through a series of interviews with providers, plan leaders and participants.
The final is a pilot program called Healthy Opportunities, which is a strategic initiative to address the social determinants that play as much of a role in our health outcomes as medical factors. A portion of the funding for Medicaid transformation will be used to address transportation, nutrition, housing and interpersonal violence with the goal of reducing visits to hospitals and emergency rooms in pilot counties across the state. Based on results of the evaluation, the program has the potential to expand across all counties in N.C.
The Gillings School evaluation team includes a host of Gillings School faculty from the Department of Health Policy and Management, including Holmes, Sandra Greene, PhD, Christopher Shea, PhD, Valerie Lewis, PhD, and Justin Trogdon, PhD, as well as affiliated faculty across the country, including adjunct faculty Marisa Domino, PhD, at Arizona State University College of Health Solutions and Paula Song, PhD, at the Virginia Commonwealth University College of Health Professions.
“This partnership with the state exemplifies the commitment of the Gillings School to improve public health by bridging research and real-world application,” said Kristin Reiter, PhD, professor and chair of health policy and management. “Faculty are using their expertise to help drive positive change for the people of N.C. through evidence-informed policy decisions.”
In fall of 2023, the NCGA voted to expand Medicaid eligibility based on the provisions of the Affordable Care Act, meaning more North Carolinians are now eligible to access health care coverage through Medicaid. The expansion provides much needed stability to people who have struggled to find health care coverage or lost the temporary Medicaid benefits that were enacted under the COVID-19 public health emergency.
“Anytime you have turbulence in coverage, that can be disruptive to maintaining quality health,” Holmes explained. “Part of our evaluation is also looking at how that access to coverage affects people’s health outcomes.”
As a whole, Holmes says the evaluation is an opportunity to understand the methods and metrics that the state is using to reshape a system that impacts the health of millions of N.C. citizens.
“This is an enormous transformation that’s made up of multiple small levers, and each one has an impact,” he said. “This project helps us to evaluate how changes to each lever affect participants as they navigate the health care system and then identify opportunities that improve health outcomes and keep people out of the hospital more effectively.”
The UNC-led evaluation is projected to run through 2027, and the results will be released to the public after review by CMS.
