Ground-Breaking Fee Schedule for Social Determinants of Health
NC Healthy Opportunities Pilots to get underway
North Carolina is pushing forward with an expansive effort to transform its Medicaid program from largely Fee-For-Service into managed care. There is a lot to unpack in their proposal, and perhaps I’ll write more about that another day. For today, I’ll focus on NC’s effort to reimburse for Social Determinants of Health (SDoH) under this effort.
Could North Carolina’s work be a harbinger of what is to come? Let’s take a look.
“All North Carolinians should have the opportunity for health. Access to high-quality medical care is critical, but research shows up to 80 percent of a person’s health is determined by social and environmental factors and the behaviors that emerge as a result. DHHS is focusing on tackling these fundamental drivers of health. -North Carolina Department of Health and Human Services (DHHS)
Part of North Carolina’s approach for transforming Medicaid includes the Healthy Opportunities initiative. Initially, NC DHHS says this will focus on four key SDoH areas: housing stability, food insecurity, transportation and interpersonal safety. Strategies to be used include:
- Creating an interactive statewide map of SDoH indicators that can guide community investment and prioritize resources
- Developing a set of standardized SDoH screening questions
- Building a statewide coordinated care network (NCCARE360) to connect those with needs to available resources. (I wrote about this last year and their use of the Unite Us platform.)
- Incorporating SDoH strategies throughout the state’s Medicaid 1115 wavier
- Building up a Community Health Worker Initiative
- Examining better ways to streamline cross-enrollment in existing key benefit programs
In addition, one strategy I found intriguing is the Healthy Opportunities Pilots which will specifically “test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety to high-needs Medicaid enrollees.” NC received approval from the Centers for Medicare & Medicaid Services (CMS) to do so under its approved 1115 waiver.
The state will select several “Lead Pilot Entities” (LPE) that will develop and oversee a network of service organizations (called Human Services Organizations, HSOs) in a defined geographic area. Prepaid Health Plans (PHPs) and their care managers will work with the LPEs to connect patients to these HSOs in order to access SDoH interventions.
North Carolina’s Payments for SDoH
I think we all realize the role that non-clinical factors can play in an individual’s health, but there are many questions left to answer, such as: which intervention(s) or combination help the most; what is the evidence-base for an intervention; and, ultimately, who pays. The NC initiative seeks to help provide some answers.
Under the pilots, reimbursements are available for a select number of approved SDoH interventions when provided to approved/qualifying individuals. Qualifying individuals must have at least one health criteria (e.g.: an adult with multiple chronic conditions, a child with three adverse childhood experiences) and one of the four previously mentioned social risk factors.
CMS has already approved NC’s reimbursements under the first-of-its-kind SDoH fee schedule. There are 29 reimbursable services across the four domains. Here is a sample.
There is still much work to get done before the pilots actually launch. As of now, the deadline to submit a proposal to be a Lead Pilot Entity closed on January 21, 2020. Next steps in the process are:
- LPE selection is expected in April 2020
- LPEs will build out networks into early 2021
- Pilots would then launch in the spring of 2021
What NC’s effort does is pave a path for a systematic, uniform approach to SDoH coverage and payment. Only time (and a robust analysis of data/outcomes) will tell whether the pilots are successful. If so, expect NC to expand SDoH interventions further across its Medicaid program. I can imagine other states will also seriously investigate incorporating aspects into their own Medicaid programs. And beyond Medicaid, there is a lot of interest already related to SDoH. From Medicare Advantage plans (through supplemental benefits) to health care entities, foundations and organizations, the results of the pilots could be widely leveraged.
I’ll be watching with interest as their effort gets fully underway.
What are your thoughts?
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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