Healthy Opportunities Pilot
This spring, North Carolina took major steps forward in launching their Healthy Opportunities pilot program. This pilot is focused on building a system for Medicaid reimbursement for "evidence-tested, non-medical interventions". An example of that type of intervention is food. Specifically, the pilot sets a reimbursement structure for:
Food and Nutrition Access – Case Management Services
Evidence-Based Group Nutrition Classes
Diabetes Prevention Program
Fruit and Vegetable Prescription
Health Food Boxes (for Pick Up or Delivered)
Healthy Meal (for Pick Up or Delivered)
Medically Tailored Home Delivered Meal
The detailed descriptions and fee schedule can be found here. (Along with non-food-related services).
This pilot received a lot of attention in its planning phases for the work done to build the service fee schedule. The published schedule reflected a robust public input process and estimates from community organizations currently providing services. It was ambitious in trying to cover a broad menu of evidence-backed services. There are a few caveats, however, in interpreting the results as they might apply in Vermont:
North Carolina's Department of Health and Human Services (NCDHHS) has positioned this program as a bridge toward value-based care, and hopes to look at many of the pilot project's results in light of how they can inform that transition. There is no reason to assume that North Carolina and Vermont will have the same path or timeline to reach a fully value-based reimbursement system – although it is generally true that a lot of states are looking to build these types of bridges (here in Vermont that is how we positioned our fee schedule for audio-only telehealth, it is not an unfamiliar concept!).
NCDHHS anticipates that there will be philanthropic funding to support some of these projects in addition to state and federal dollars. Because this is a far reaching pilot, there are many opportunities for other funders to build on the foundation set by the NC fee schedule. The world of charitable foundations investing in health care innovation looks different in Vermont compared to other states and we do not have the same opportunities for match.
The fees were based on community input if there were no comparable services already recognized by CMS – this is why, for example, the Medically Tailored Meals (MTM) cost estimates look suspiciously similar to the payment schedule we see our Area Agencies on Aging use for home delivered meals. Those reimbursements don't necessarily match the actual costs, plus services that seem "comparable" in general may not be comparable in practice. For example, this 2015 Mathematica study provides details on Older Americans Act-funded meals (often the benchmark for meal pricing). A trend seen then that remains strong is use of volunteer labor for meal production. That cost saving solution is not as viable for MTMs, which are handling much more complicated individualized meal plans, with high volume production, and a need to closely match nutritionist guidelines.
The fee schedule relies on statewide averages for costs like labor and delivery. We could reasonably expect that, for example, the meal delivery costs in metropolitan North Carolina would not match the costs in rural Vermont. (Admittedly, it would have been a lot to ask for North Carolina to do a county-by-county break down of costs so that we could find the region that looked most like Vermont. . . ).
Do not let caveats stand in the way of appreciating the information available from the North Carolina project. Check out the links below for details.
Pilot Service Fee Schedule & Service Descriptions - see this Commonwealth blog post for a short summary as a preface to the fee schedule
KFF Issue Brief – Note that the timeline described here relied heavily on work originally scheduled in 2020 and has since been revised. This brief provides short, general background on 1115 waivers as well.
Another interesting element of the NC Healthy Opportunities pilot is their use of Lead Pilot Entities. Vermont has long recognized the importance of creating a structure for health care providers, social service providers, community organizations, and community members to come together to set goals and work collaboratively towards better health. We discussed this framework as it relates to food in a 2021 Policy in Plainer English podcast episode. North Carolina spoke to this topic as part of a panel hosted recently by Manatt.
There is one specific role related to bridging health care and non-healthcare partners that is growing in importance. That role is for an integrator organization that can both facilitate collaboration and also handle the administrative, regulatory, and billing requirements of health care. If all goes according to plan, the LPE structure in North Carolina will allow smaller community organizations to provide services and be paid by Medicaid dollars, without themselves setting up a Medicaid billing and compliance system.
The Healthy Opportunities Pilot program won't be fully operational until Spring 2022, but we'll continue to track the results for useful lessons learned!