Social determinants are core of North Carolina's Medicaid overhaul

North Carolina's managed-care organizations will be required to screen every Medicaid beneficiary for access to food, stable housing and transportation once the state transitions its fee-for-service Medicaid program to managed care in 2019, depending on regulatory approval.

The requirement is just one of the ways the state is transforming its Medicaid program to focus on patients' social determinants as the main drivers of health outcomes. North Carolina asked the federal government last year for permission to overhaul Medicaid and expects to hear an answer in the coming weeks.

The importance of the social determinants of health has been a buzzy topic in 2018. Hospitals and health insurers have launched initiatives left and right to ensure low-income or elderly patients have nutritious foods or rides to the doctor's office. But many of these programs and the ones that came before them are one-off pilot projects.

North Carolina is trying to make taking care of patients' social and environmental needs a sustainable, everyday part of a healthcare organization's workflow, Dr. Mandy Cohen, the secretary of the North Carolina's Health and Human Services Department, explained Friday at Modern Healthcare's Women Leaders in Healthcare conference in Nashville. She described the goal as buying health—not healthcare.

Looking beyond what happens in the hospital or clinic is becoming the financial imperative for U.S. healthcare organizations as they move toward alternative payment models and take on more financial risk for a patient's health, said Cohen, who took on the role of secretary in January 2017 after serving as chief operating officer and chief of staff at the CMS during the Obama administration.

"This is not new stuff, but what I think is a game-changer in this moment is this link between focus on social determinants and understanding it in a different and deeper way, and all of the value-based purchasing and alternative payment models that are going on at the same time," Cohen said.

More than 2 million North Carolinians are enrolled in Medicaid. It is one of the 18 states that did not expand Medicaid under the Affordable Care Act, so Cohen's team has limited tools and funds to work with.

The department started off with collecting and merging lots of data on food deserts, transportation access, housing, income levels and other health indicators to create a map showing communities that needed the most help. Existing organizations already investing in health can use the hot spot map to figure out where to focus their resources, she said.

The department also took six months to develop a standardized tool that physicians or case managers would use to screen patients for their social determinants of health and is piloting it in 40 to 50 different settings, Cohen said.

Managed-care organizations will be required to use the tool to screen all Medicaid beneficiaries starting next year.

North Carolina is also building a resource platform so that once a patient's social determinants are pinpointed, providers can connect that patient to organizations that can help.

"There are resources in the community often underutilized, whether it's a food bank, a domestic violence shelter or an adolescent program to help kids who are at risk, but folks don't know about them," Cohen said.

The platform, which will be free and rolled out across the state over the next two to three years, will allow providers to refer patients to the right community resources just like they would to a healthcare specialist, and make sure the patient showed and follow up if the patient didn't. For now, the resource platform is being paid for by donations from health systems, payers and foundations in the state.

North Carolina has asked the CMS for $800 million to run a few regional pilots to find out what food, housing, transportation and interpersonal violence interventions would best move the needle on health and costs.

"We're not buying a house for everyone—let's be honest," Cohen said. "We need to scale to the thing that is going to move the needle, but can be the most efficient, least expensive type of intervention."

The goal is to incorporate the most successful pilots into the Medicaid managed-care program. Another goal is move all North Carolina managed care organizations to have 50% of their payments in alternative payment models by the end of the second year after transitioning the Medicaid program.

"In a value-based context, the folks who figure out how to buy health and not just healthcare are going to be most successful," Cohen said.

This story has been updated to reflect the correct deadline for managed-care companies to have half of expenditures in alternative payment models.