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Skyline of Charlotte, North Carolina shows skyscrapers, trees and highways against a bright blue sky.
The skyline of Charlotte, North Carolina is seen. The state is significantly changing the way health care is paid for and delivered. (Getty Images)

Building State-Specific Recommendations to Support Integrated Care for Dual-Eligible Individuals

North Carolina is undertaking a transformational effort to integrate care for individuals dually enrolled in Medicare and Medicaid.

North Carolina is in the midst of a significant shift to change the way health care is paid for and delivered. Since July 2021, Medicaid beneficiaries have been transitioning from fee for service to managed care organizations (MCOs) with the goal of delivering high-quality, high-value care to all beneficiaries. The managed care transition will continue in December 2022 with the launch of tailored plans for beneficiaries with behavioral health needs and/​or intellectual and development disabilities, followed by the development of an integrated care model for dual-eligible beneficiaries within the next five years. 1 Dual-eligible individuals, who have both Medicare and Medicaid, comprise low-income older adults and people with disabilities, many of whom use behavioral health and long term services and supports. This population on average is in worse health and uses more health care services than their Medicare-only peers, and the lack of coordination between Medicare and Medicaid can result in care gaps and costly, avoidable hospitalizations and nursing home stays. 

To inform the future reforms, Arnold Ventures is supporting a project led by the Duke-Margolis Center for Health Policy to develop policy and programmatic options for North Carolina’s Department of Health and Human Services (NCDHHS) to deliver integrated care for dual-eligible individuals. This work aims to recommend options for Medicare-Medicaid integration that reflect the unique needs of dual-eligible North Carolinians, NCDHHS priorities, and the perspectives of the stakeholder community. Mike Leighs, deputy director of engagement at NCDHHS, echoes the importance of this work, saying, We are excited to strengthen our partnership with our academic colleagues in the state to ensure that our approach is an innovative and evidence-based model that makes North Carolina a national leader in providing high quality, coordinated, and integrated care for Medicaid and Medicare beneficiaries.”

We are excited to strengthen our partnership with our academic colleagues in the state to ensure that our approach is an innovative and evidence-based model that makes North Carolina a national leader in providing high quality, coordinated, and integrated care for Medicaid and Medicare beneficiaries.
Mike Leighs deputy director of engagement at NCDHHS

States are using multiple approaches to care integration — Dual Eligible Special Needs Plans (D‑SNPs), the Program for All-Inclusive Care for the Elderly (PACE), and demonstration models through the Centers for Medicare and Medicaid Services (CMS), yet those models are not turnkey. To effectively design programs for their entire population of dual-eligible individuals in an efficient and affordable manner, states need input and analysis to inform how to incorporate the needs of specific subpopulations, through covered services, plan requirements, and program infrastructure. 

To develop recommendations for Medicare-Medicaid integration in North Carolina, the Duke-Margolis team is using a systematic research process that combines stakeholder engagement with qualitative and quantitative analysis, including using linked Medicare and Medicaid claims data for the dual-eligible beneficiary population. 

  • Stakeholder engagement: In collaboration with NCDHHS, the Duke-Margolis team convened an advisory panel of experts from North Carolina and across the country. The team conducted additional stakeholder interviews and focus groups with plans, providers, consumer groups, community organizations, and others to help understand challenges and solidify priorities for integration. The deep engagement with stakeholders both within and outside the state informed the proposed vision and goals for Medicare-Medicaid integration.
  • Data analysis: Recommendations are informed by data analysis that aims to describe geographic and demographic variation among North Carolina dual-eligible individuals, enrollment rates and changes over time, and Medicare/​Medicaid spending for need-based subgroups.

Through this work, the team has identified three priorities for the state to use when developing an integrated program, while ensuring that effective managed care oversight and cost savings will be critical to the state’s success. 

Beneficiary and Caregiver Experience and Outcomes: Stakeholders stressed the importance of improving the beneficiary experience and ensuring a focus on health outcomes. Key aspects for integration include: 

  • Building a system that empowers beneficiaries and their caregivers with the information they need to make decisions;
  • Creating a seamless care experience for beneficiaries and caregivers through integration of care across all settings, including the home, community, and nursing facilities;
  • Ensuring access to timely, high-value care and having a single point of contact to help beneficiaries navigate the system.

Addressing Health Equity: Minority populations often have more significant health needs, and the proportion of non-white dual-eligible individuals (41%) in the state is higher than the number of non-white Medicaid-only beneficiaries (15%). Based on the demographics, it is important to focus on strategies that can be effective in reducing health disparities. Some of these strategies could include: 

  • Establishing caregiver and community supports that can improve beneficiary engagement and build broader trust in the health care system,
  • Providing respite care and/​or financial or non-financial remuneration for caregivers,
  • Offering information and resources in the beneficiary’s preferred language, and
  • Collecting and using appropriate race, ethnicity, and language data (REAL data) to tailor programs and assess progress towards health equity goals.

Need For Continued Community Engagement: With numerous components of North Carolina’s Medicaid transformation already underway, sustained community engagement is needed to support beneficiaries and their families understand the impact of care transitions, especially for complex populations. Ensuring streamlined procedures regarding benefits, member services, communications, processes, and appeals will help beneficiaries have sufficient access to the information and support that they need.

The North Carolina experience with integration can serve as an example for states nationwide on how to navigate this complex transformation and how to align key elements of duals integration with broader state health goals and programs. Developing and implementing an integration strategy is a significant investment of time and resources for states, but ultimately, these investments will ensure meaningful improvements to the health of dual-eligible beneficiaries and their families.

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    These changes align with broader statewide efforts to transform healthcare, including increasing adoption of provider value-based payment models; Healthy Opportunities Pilots, which direct resources toward social and community service providers to lower costs and improve outcomes; and the supportive NCCARE360 network, which helps connect providers with community-based organizations and social service agencies. Collectively, the state aims for these programs to better enable providers to deliver beneficiary-centered care in the community and allow for a more localized care management infrastructure tailored to beneficiary needs