5 years is just the beginning: NC Medicaid’s transition to managed care

Five years ago this month, North Carolina fundamentally changed the way it delivers healthcare for nearly three million Medicaid beneficiaries. By modernizing the Medicaid program from a traditional fee-for-service system to a managed care model, our state embraced a better approach — one focused on improving healthcare outcomes of our citizens rather than simply paying for the volume of Medicaid services delivered.

The managed care model embodies a patient-centered philosophy by emphasizing prevention, proactive communication, accountability, continuity of care and better outcomes. It mirrors the overall commitment to value-based care that is operating in 42 states across the country, and it positions North Carolina to be a national leader in Medicaid service and cost-effectiveness.

Five years after this monumental transition, the results underscore why the decision to embrace a new approach to healthcare continues to benefit patients, providers, and taxpayers alike.

For patients, the difference is tangible. Care no longer begins and ends with a doctor’s appointment. With Medicaid managed care, today’s beneficiaries have access to care managers who help coordinate appointments, navigate chronic illnesses, connect families with behavioral health services, and address social drivers of health before they become medical crises. Through innovative programs like Healthy Opportunities, North Carolina has demonstrated that addressing housing, nutrition, transportation, and other social factors can improve health while making healthcare spending more cost-effective.

Providers are now operating within a system designed to reward quality over quantity. Physicians have greater insight into the health of their patients, access to meaningful clinical data, and support that helps them coordinate care across multiple settings. The result is a stronger physician-patient relationship focused on improving outcomes

The four managed care organizations who have been entrusted to administer North Carolina’s Medicaid program have served a critical function during this transition. Health plans invest in care management resources, provider education, pharmacy oversight, and sophisticated data analytics tools that help identify care gaps before they become costly health events, all while working to ensure access to quality care regardless of zip code.

The plans also invest in communities across North Carolina, maintaining a local presence that helps strengthen the systems of care that communities rely on. Just as importantly, they work alongside providers and state leaders to strengthen program integrity by identifying instances of waste, fraud, and abuse, ensuring Medicaid dollars are spent where they have the greatest impact. Collaboration of this sort simply wasn’t possible under the fragmented fee-for-service model.

These successes do not signal a finish line. Healthcare continues to evolve, and so do the needs of Medicaid beneficiaries. As North Carolina continues expanding value-based care initiatives, integrating physical and behavioral health, strengthening care management, and addressing the social factors that influence health, the managed care model is well positioned to meet those challenges.

Five years after this historic transition, North Carolina has demonstrated that Medicaid can be more coordinated, more accountable, and more focused on outcomes than ever before. That is something worth celebrating.

More importantly, we now have a solid foundation in place, and past successes provide confidence that the strongest chapters of North Carolina’s Medicaid story are still ahead. By continuing to invest in innovation, partnership, and integrity, we can build on this momentum and ensure NC Medicaid remains a quality-driven, sustainable program for the millions of North Carolinians who depend on it.

Peter T. Daniel is the executive director of the NC Association of Health Plans, Inc.