Genesis Health Consulting entered the month of May having just returned from the Pediatric Academic Societies (PAS) Annual Meeting. The PAS meeting brings together pediatricians, researchers, health care providers, and other academics to “improve the health and well-being of children”. Our last blog post focused on A Roadmap to Reducing Child Poverty released by the National Academies of Sciences earlier this year. The Healthy Opportunities model in North Carolina was another topic of discussion and excitement at PAS.
Healthy Opportunities is more than a singular program or strategy. The model is “efficiently and strategically investing in health” in order to fully realize the mission to improve health, safety and well-being of every person residing in North Carolina. This means a focus on the social determinants of health, or those influences on health driven by where people live, work and play.
What particularly stands out to us about this model is the realization of a model that is reflective of partnerships between the state department of health, payers, philanthropy AND community organizations. It is often recognized that staying in our “lanes” or “silos” doesn’t benefit anyone; yet it is still uncommon to see models that successfully embrace collaboration.
A large component of Healthy Opportunities are the pilot projects anticipated to launch later this year, aligning with the transition of North Carolina Medicaid from primarily fee-for-service to Medicaid Managed Care. The provision of care management services is a critical component of this transition, and local health departments will be contracted for the provision of this service. More detail about this transition can be found here. The Healthy Opportunities Pilots will allow for managed care plans to pay for Centers for Medicaid Services (CMS)-approved evidence-based programs which directly address housing instability, transportation insecurity, food insecurity, interpersonal violence and toxic stress. Here is where the partnership comes in. While the managed care plans will be identifying people who could benefit from the programs, community-based organizations will deliver the services and receive payment for these services. This relationship between community-based organizations and Medicaid will be facilitated by a “lead pilot entity”.
The definition of the “lead pilot entity” is broad and can include community-based organizations, health service organizations, or even a partnership of several organizations. Of paramount importance, the lead pilot entity must be “rooted in the community, understand community dynamics,” be financially stable, have capacity to identify community resources, and be able to facilitate the collaboration of a network of organizations with no known history of previous long-term partnership. Additional information about the role of the organizations involved in the Healthy Opportunities Pilots can be found here.
An example of the types of services that will now be covered is described below:
“A Medicaid-enrolled child with asthma has repeated visits to the emergency department (ED) because of asthma attacks brought on by her apartment’s moldy carpet or broken air conditioner. This is both traumatic for the child and her family, and costly for the health system. [Healthy Opportunities] Pilot funds can be used to replace her carpet or fix her air conditioner, improving control of her asthma and reducing ED visits and hospitalizations.” North Carolina’s Healthy Opportunities Pilots: A Review of Proposed Design for Interested Stakeholders
Given this will be the first time CMS has paid for these types of services, the Healthy Opportunities Pilots will be developing a fee structure to determine payment amounts. Currently the NC Department of Health is requesting information from health service organizations to inform the development of this fee structure which will be submitted in July 2019. A variety of payment structures are planned to be used including fee-for-service, cost-based reimbursements, and bundled payments. These payment structures are reflective of the types of services that could be offered. For example, fee-for-service payments will be for those types of services that can reasonably be estimated in advance (e.g., consults with social workers); cost-based reimbursement payments would be used for services where prices are set by contractors (e.g., exterminator fee for ridding home of pests); and, bundled payments are for more longitudinal services, so that needs can be meaningfully addressed.
We are excited to watch the development of the North Carolina Healthy Opportunities model, including the evaluation of the pilot outcomes in the coming years. Additional information and detail about the proposed design of the model and the plan for evaluation can be found in the policy paper here.
Genesis Health Consulting has experience in bringing partners together to facilitate meaningful change to improve the health of children and families. Please email us info@genesishealthconsulting.com to discuss more!
Disclosure: Dr. Veronica Gunn, CEO of Genesis Health Consulting, is a board member of THI, an organization providing strategic guidance to North Carolina on the development of this model.