By Liora Engel-Smith

As the state health department races to roll out an ambitious plan that would tie Medicaid payments to patient health outcomes, at least one regional provider has expressed concerns about the implication of the so-called transformation.

The state health department plans to move 1.6 million Medicaid recipients to the pay-for-value system on Feb. 1, but a protracted budget dispute between Gov. Roy Cooper and the General Assembly, largely over Medicaid expansion, may delay that timeline. At a meeting earlier this month, lawmakers said a July 1 start date may be more feasible even as Health and Human Services Sec. Mandy Cohen warned that such a delay would be costly.

But for at least one provider, the plan’s go-live date isn’t the only uncertainty. With Medicaid transformation, the state will increase its focus on the social determinants that play an outsized role in people’s health: poverty, transportation access and living conditions to name a few.

Reuben C. Blackwell, IV, who heads OIC of Rocky Mount, a community health center that also offers education opportunities, hopes the state’s payment structure will take into account this big vision.

Thus far, he said, his organization has “more questions than answers.”

Breaking a vicious cycle

In Rocky Mount the interplay of health and social challenges — poverty, housing instability and more — on health is crystal clear. A city of 54,000, Rocky Mount straddles what locals call “the twin counties.” Separated by train tracks running through the center of town, Edgecombe and Nash Counties may as well be worlds apart. Edgecombe, the poorer of the two counties is predominantly African American and has some of the poorest health outcomes in the state.

Its more affluent twin, Nash County, is whiter and more economically stable. Residents there generally fare better on health outcomes.

A map of Rocky Mount that shows health disparities among between the Edgecombe County and Nash County sides. Medicaid transformation is slated to help people in Rocky Mount who are struggling because of social determinants of health
A map of Rocky Mount shows that the much of the Edgecombe County side is economically fragile (denoted in red and yellow), while much of the Nash County side is economically stable or strong (denoted in green). Photo courtesy of OIC of Rocky Mount.


OIC cares for many of the most vulnerable residents of these counties in its seven locations. Out of roughly 9,000 patients, Blackwell said, 60 percent are on Medicaid. Another 20 percent have no health insurance. Many of the patients, insured or not, struggle with chronic diseases, poverty, housing instability and more.

Providers at OIC do the best they can to educate patients and give them access to medications they need.

Blackwell worries that the new payment structure will penalize the community health center for not being able to resolve all the challenges that prevent patients from reaching their full potential. These barriers to health may be bigger — and costlier — for an organization such as his to tackle.

Blackwell said that through negotiations with the Department of Health and Human Services, community health centers have secured the same amount of Medicaid funding they get now, at least in the first stage of the transformation. But he isn’t sure what would happen to OIC’s payments after that initial period.

“We have to be adequately compensated for the work that we’re doing and for the risk that we’re taking,” he said.

Nathan Long, pharmacy director at the community health center, put it this way: Many of his patients cannot afford to pay for their medications and for food, he said.

A white man speaks to the microphone. He is pharmacy director Nathan Long and he brought up concerns about Medicaid transformation
Nathan Long was among the OIC staff who spoke about concerns over Medicaid transformation at a recent meeting. Photo credit: Liora Engel-Smith.

“They’re gonna choose their meal over their medication and they’re gonna lose their outcomes,” he said. “Their A1C [a measure of blood sugar management] is not going to be controlled, their blood pressure is going to be high and that all feeds back into their social determinants. It’s a vicious cycle.”

In an interview this week, Cohen said the outcomes will be measured at the population level, not at the level of individual providers. She provided assurance that DHHS will have a rate floor to guarantee that providers aren’t paid too little.

“If folks are concerned, we want to understand that a little better and see what we can do to either alleviate anxiety or change something if there is really a problem,” she said.

Healthy Opportunities

State health department officials have a plan to address some of the needs Blackwell and Long identified. The state is launching Healthy Opportunities, a project that will fund pilots that focus on social barriers to health. The Centers for Medicare and Medicaid Services authorized up to $650 million over the next five years for these initiatives, which the state says will focus on the highest-need Medicaid enrollees.

An infographic about the factors that contribute to premature death. Social factors and environment make up 60 percent of the risk.
Infographic credit: Liora Engel-Smith.

Blackwell said his organization plans to take part in a pilot project of this kind and has sought to make a difference in the lives of their patients in other ways. Sometime last year, OIC and other local organizations received a grant from Blue Cross Blue Shield to study and address housing barriers to health in their service area. Blackwell said OIC and its partners are in the process of studying the region’s housing needs and formulating a plan to address those needs. It will be a while before the program moves beyond the planning phase, and the transformation is likely to take effect first.

In the meantime, enrollment for the new Medicaid plans is underway and is expected to run until December. Thus far, 70,000 beneficiaries signed up for a managed care plan, Cohen said earlier this month. Those who don’t sign up by the deadline will be automatically assigned to a plan, but they can change their selection at any time.

But the sign-up process itself has been rife with confusion, Blackwell said.

Many of OIC’s clients are expressing confusion, saying they’ve found it hard to navigate the state’s website because of low literacy or lack of internet access, Blackwell said. OIC has designated two staff members who have been doing nothing but helping people sign up since open enrollment began, he said.

Inclusion, opportunity and struggle

Blackwell believes that despite the challenges ahead, his center, and the community, have a decent shot at meaningful progress. On a recent afternoon, Blackwell spoke to a group of journalists at the former Booker T. Washington High School about that hope.

The faded structure, which also serves as OIC’s headquarters, has long brick hallways that are reminiscent of its past. But the modest building is a source of great pride for the community. During the Civil Rights era, Rev. Dr. Martin Luther King Jr. visited the Rocky Mount High School in 1962 to test his famous “I Have a Dream” speech. The gathering was supposed to happen at the school’s auditorium, but so many people showed up that King gave his speech at the nearby gymnasium.

OIC is steeped in that legacy. Rocky Mount, Blackwell said, has always been and will be a place of “inclusion, opportunity and struggle.”

In the days to come, the parameters of transformation will become clearer, and the center will adapt to the new realities, Blackwell said.

“We don’t know what’s gonna happen until this enrollment period is over,” he said. “We have to see how many patients across North Carolina are enrolled online and then we’ll be able to see what kind of universe each of us is working with and then we’ll know what’s possible.”

NC Health Reporter Sarah Ovaska-Few contributed to this report.

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...

One reply on “In Medicaid transformation rollout, ‘more questions than answers’”

  1. Thanks for reporting this and explaining the challenges that community health care providers face and the social and historical context that the have to deal with.

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