By Clarissa Donnelly-DeRoven

This is the second story in a series examining how NC Medicaid’s Healthy Opportunities Pilot is going

What would it mean for a health care program to actually pay for the things that help people be healthy, instead of just paying for care once they get sick? 

That’s what North Carolina’s Medicaid office started trying this past March when the program launched a first-of-its-kind program: the Healthy Opportunities Pilot, or HOP for short. 

HOP’s aim is to see if the state can improve the health of patients on Medicaid by paying for non-medical things that might prevent them from getting sick — fresh produce, or first month’s rent, for example. These things are often called social determinants, or social drivers, of health.

“The last five years or so people and institutions, including national health policy and government bodies, are starting to recognize that social determinants of health actually play probably a larger role in health outcomes than than just medical care,” said John Purakal, an emergency medicine doctor at Duke who oversees a program that screens patients in the ER for unmet social needs and connects them to resources.

The care patients get in a doctor’s office obviously does impact them, but multiple studies show that what happens to patients outside of that medical visit — where they live, what they eat, who they spend time with — has a far greater impact on their health. 

While some social problems, such as domestic violence, impact people across class lines, others are inextricably tied to and exacerbated by factors such as income or access to transportation. 

That’s partly why offering these services to the low-income people on Medicaid holds such potential. 

Since the program is the first of its kind in the country, some bumps and growing pains were expected. And to be sure, those participating in the pilot have documented plenty. 

They argue that these issues shouldn’t cause panic, but also that revisions need to happen as quickly as possible, both so HOP can prove its worth and so people can get access to the care that they’re entitled to.

How does it actually work?

Case managers who work at one of the five insurance companies responsible for the majority of Medicaid beneficiaries act as the program’s gatekeepers. They identify someone with  Medicaid who is “high cost,” meaning they’re using expensive services – such as the emergency room – a lot. 

The care manager reaches out to that person and sees if they have one or more chronic health conditions (diabetes, substance use disorder, chronic heart disease, etc.) and one or more unmet social needs: Do they struggle to afford groceries? Are they having trouble paying rent? Are they afraid of somebody they live with?

If they answer yes to questions in both sets, they’re eligible for services provided under the HOP pilot. The care manager then refers that person to a nonprofit in their area, called a Human Service Organization, that offers resources to deal with whatever issue they have. 

Unlike insurance companies, most of these local organizations have deep roots in their communities. 

After the local organization has worked with that Medicaid patient, they submit an invoice to the insurer — as a health care provider would — to be reimbursed for services provided. 

That’s the simplified version. 

In reality, it’s a complicated web of entities with many steps and handoffs. Sometimes it works like a well-oiled machine, and other times it’s like there’s no machine at all, just a series of gears grinding against each other. 

Money waiting for a client 

Perhaps the most significant problem area, according to multiple human service organizations, is the referral process.

That’s the case in Madison County where there’s an affordable housing crisis, much like most of western North Carolina. The Community Housing Coalition of Madison County, a human service organization in the HOP program, conducts preoccupancy home inspections. They can also help pay for pest and mold removal, along with other critical repairs. 

But, they haven’t gotten any client referrals.

“We have gotten a couple attempts at referrals, I guess, if you want to call them that,” said Leigh Waters, the client services coordinator at the organization, during the first week of August. They had to reject these referrals because although the people had Medicaid, they didn’t actually qualify for the HOP pilot. 

“I definitely see the need,” she said, “and I also see on the other hand these funds that HOP does have and so it’s frustrating to know there’s money there that’s not being spent.”

Amy Upham, the executive director of Eleanor Health Foundation in Buncombe County, said her organization is seeing the same thing. The organization works with people who have substance use disorder and other mental illnesses and connects them with transportation, housing, affordable medications, employment and more. During their regular work each month, they get about 100 applications requesting various kinds of financial assistance. 

Many of those folks are on Medicaid, and therefore eligible. 

“We could potentially be serving 30, 40, maybe even 50 people a month who are on Medicaid, and we’re getting three referrals a week,” she said.

‘Passing the buck’

Waters explained that she’s met with a couple of people who seemed like they would be eligible for the HOP pilot, but she can’t actually enroll anyone in the pilot. 

“Right now, the best that we can do is tell a client that we think may be a fit for the referral to call the number on the back of their Medicaid card, and hopefully get referred that way,” Waters explained.

“That itself is not the best way because we are dealing with the elderly population,” she said. Sometimes those clients can’t read the tiny writing on the back of their card — if they even know where their card is.

“If they have to be on a phone call for 30 minutes to an hour just to get to something, I think it’s probably hard for them to see the incentive in that phone call,” she said.

That chain of referral also touches on something else for Charam Miller, the director of the Macon Program for Progress.

“It feels like you’re turning somebody away when you say ‘please go ahead and call the number on the back of your card,’” she said. “It kind of feels like we’re passing the buck, and if somebody’s hungry or if somebody’s in need of services, I want to see that need met.”