In this episode, we talk to Denise Tedder, former teacher, ED Nurse, and now Quality Programs Manager specializing in Medicaid for CHESS Health Solutions about North Carolina’s transformation to Managed Medicaid Care, Medicaid Expansion, and what healthcare can do to prepare for the influx of a new population of patients into the program.

Denise Tedder, thank you for joining us today on the move to value podcast!

Thank you, Thomas it's a pleasure to be here.

I have a couple of questions for you about Managed Medicaid. So can you tell me a little bit about the move to Managed Medicaid in North Carolina?

Sure. Well it started back in like 2015, they passed legislation transitioning Medicaid from a fee for service to managed care and what that means under managed care the state contracts with insurance companies, which are paid a predetermined set rate for each enrolled person to provide the services. North Carolina Medicaid Managed Care actually started back in July 1st 2021. So now our patients have options to choose a health plan and get care through the health plans’ network of doctors. Fast forward to now, effective December 1st, North Carolina has passed Medicaid expansion which will provide an estimated 600,000 more North Carolinians with access to health care coverage.

That sounds like a really good opportunity for a lot of folks to get the healthcare coverage they need.

Yes, it's going to be amazing for our communities!

So what opportunities are there, you know because CHESS is in the value-based care space, right? So what opportunities are there for managed Medicaid to accelerate that?

So, one of one of the key features of North Carolina's Medicaid, Managed Medicaid program is the requirements of all the pre-paid health plans to align their population health and prevention strategies with the state’s goals. The ultimate goal is obviously to make everyone healthier under Medicaid but there's opportunities to reward providers for keeping their patients healthy. This expansion means more people will have access to healthcare which improves their health and that's what it's all about.

What does that do with the improvement perhaps of health equity in our communities?

So, it just means that everyone has the opportunity to be as healthy as possible. It gives patients increased access to preventative care for things like well visits, immunizations, screenings, and it also causes for better management of chronic conditions. So having this equitable access to healthcare means we're focusing on keeping our communities healthy which will positively impact health outcomes.

So, how does this address the social determinants of health?

So, Medicaid programs are increasingly focused on social determinants of health needs, including food insecurity, access to housing, reliable transportation. I recently read an article from the CDC which said 40% of a person's health outcomes are driven by their social determinants of health. So, I mean no one can focus on a health problem that they have when they're worried about housing or food for their family. With a focus on these needs we can put them in the best position to be successful.

And what are your thoughts on how prepared providers are for this December 1st expansion deadline we have?

Well, one of the big challenges for providers will be a sudden increase of all the patients seeking care. So, we have 600,000 across the state and most of our providers are operating at or near capacity. So, it could cause short term delays in scheduling appointments, but having this, you know, this previously underserved population access to care, I think providers are ready to make a difference.

That's great! Well, according to “North Carolina for Better Medicaid,” 82% of Medicaid beneficiaries have a favorable view of their coverage under managed care. So what are some of the areas of opportunity that lie there?

Well, Thomas, there can never be enough social determinants of health assistance and North Carolina has a pilot program right now going on called Healthy Opportunities that is evaluating effectiveness of providing direct reimbursement to community resource organizations that will provide those services. If North Carolina could expand this program and increase access for social determinant of health support, I think that would really improve a lot more health outcomes.

And how can we help patients and their providers during this transition?

So, our care management staff can help newly enrolled patients navigate the health system which can be really confusing and frustrating. Our team, our care management team, can provide coaching to help these patients achieve their care goals. For example, our trained care managers can help a patient with a chronic diabetes health condition lower their A1C by providing smart goals for them to achieve throughout a period of time. Our care team can also assist patients in finding resources in the area and we really are an extension of the primary care provider by working on the patients’ needs in between appointments. For the providers we can support our providers by regularly reporting on care management quality through our data and analytics platform, which is designed to measure progress against Medicaid guidelines and requirements.

Nice! So, tell me a little bit about your background and how your journey in health care and how you ended up being being our resident Medicaid expert.

Well I started I was a bedside nurse for most of my years um primarily working in the emergency room and so I saw a lot of these patients that I now work with coming in there for things that they just couldn't get access for because they didn't have they didn't have any insurance. So when I became a Medicaid Care Manager many years ago, I really felt like I was trying to help them make a difference by educating them on things they can do to improve their lives and the lives of their children. I've been doing Medicaid care management for over 10 years and I really love helping a program and patients who have been underserved for so long.

How do you feel about the future of where all of this is headed?

It makes me feel excited about thinking about having health equity in our state, so that everybody has access to care, because you know the ultimate goal is to have people healthy. I think our health system has been, unfortunately, looking at you know ways to treat problems once they became problems and so now we're trying to keep people healthy before they get those problems. So really focusing on the care gaps you know getting people screenings, getting people in for visits with their provider, really meeting those health goals that they have to keep them as healthy as possible.

So, Denise, now that you are here with CHESS and you're one of our top resident experts on Medicaid and helping us navigate this journey, can you explain the CHESS platform and how we can ease the transition into Medicaid?

For Medicaid managed care, there are different requirements for providers, and our platform here at CHESS can meet all of those requirements for our providers to get the make the top tier. We have a data and analytics platform that can pull in all the information that a care manager would need. We can integrate with their electronic health record, we can integrate with claims data, we can integrate with any other type of data fields, so as a care manager I have all of this information about my patient at my fingertips. I don't have to go to any other system to look for it. So, when I'm when I'm taking care of a patient I really know everything about this patient to be able to help them and meet their needs. We also are able to risk stratify, which is one of the requirements of Medicaid Managed Care. So we're able to do our own risk where we're able to find rising risk patients. Patients that may not be the highest of high or the most complex, we're able to find these patients before they get there and truly try to help them navigate and help them with some self-management skills so that they don't become that highest risk patient.

That's great! What kind of measures do we have that folks are trying to achieve in order to hit that highest tier?

So, right now the state has certain measures that our contracts are bound by. So we're working on just really touching as many Medicaid new Medicaid member lives as we can. Eventually, the state is going to push towards the quality measures. Right now, they are reporting on those measures, but providers are not penalized for not meeting them, but they are rewarded if they do meet them. I do think eventually we can help them with our data and analytics platform. We're able to pull dashboard so the provider will know at their fingertips how they're doing on their quality measures, how they're doing on meeting their contractual obligations through our dashboards and I think we could really help providers meet all their Medicaid requirements that they have.

Outstanding! So, is there anything that you'd like to add that we haven't talked about so far in our conversation today?

I would just like to add that our CHESS platform and being part of now the Medicaid pop managed care, we bring over 20 years of Medicaid care management experience. So you have trained care managers who know these patients, who know how to care for them, know how to reach them where they are to be able to make a difference in their live. And our care managers know that they are an extension of the providers that we serve, so that we really are their eyes and ears in between appointments that can help make a difference in the patients’ lives that we have.

Outstanding! Denise Tedder, thank you for joining us today on the Move to Value podcast!

Thank you, Thomas. It's been fun.