Welcome to the quarterly NC STC newsletter. These newsletters will keep you updated on STC activities and provide you with related resources and opportunities.

What is the NC STC?

The North Carolina State Transformation Collaborative (NC STC) is a public-private partnership designed to advance value-based and person-centered care through multi stakeholder alignment, with federal engagement (CMS) and state leadership (NCDHHS). North Carolina is one of four states—along with Colorado, California, and Arkansas—selected to participate in this initiative operated by the Health Care Payment Learning & Action Network (LAN). Duke-Margolis, in partnership with the NCDHHS Division of Health Benefits and the LAN, is establishing technical working groups and gathering strategic feedback to build a path forward to advance the NC STC goals across key priority areas: aligning quality measurement, strengthening coordinated and accountable primary care, enhancing health equity data, and improving data exchange.

News and Updates

North Carolina Section 1115 Demonstration Waiver Renewal Application

North Carolina is seeking to renew its Medicaid Reform Demonstration for another five-year period (November 1, 2024 to October 31, 2029). During the first demonstration period, the state began its transition to managed care and created innovative programs to better respond to the diverse needs of Medicaid beneficiaries in the state. With this renewal, the state proposes to continue implementing managed care for additional populations, expand the Healthy Opportunities Pilots program, streamline Medicaid enrollment for children and youth, improve care for justice-involved individuals, and invest in behavioral health. In public comments shared with the state earlier this month, Duke Margolis highlighted the shared momentum the existing 1115 waiver has established among stakeholders for reforms beyond the Medicaid program, such as through the NC STC’s work on measure alignment, data sharing, and health equity data. An overarching challenge will be how to bring these Medicaid and multi-stakeholder initiatives together more effectively, measure the impact, generate evidence on what works, and support improvements in delivering whole-person care.

To identify actionable steps for the North Carolina State Transformation Collaborative, Duke-Margolis has continued to engage stakeholders through 1:1 meetings, small group conversations, dissemination events, and Duke-Margolis-led convenings.

• Duke-Margolis Health Care Transformation Workgroup Meeting
• On August 1, 2023, the Duke-Margolis convened the Health Care Transformation (HCT) Workgroup to discuss performance measure alignment for the NC STC. The HCT Workgroup is comprised of strategic and technical experts focused on performance measurement and value-based care initiatives to support health care transformation in North Carolina. The participants represent a variety of organizations, including clinically integrated networks; health systems; payers/purchasers (e.g., NC Medicaid, Medicare Advantage, and commercial plans); provider associations; and the NC Health Information Exchange.
• Duke-Margolis NC Health Care Reform Executive Roundtable Meeting
• On September 6, 2023, members of the North Carolina Health Care Reform Executive Roundtable discussed several opportunities to make progress on NC STC priority areas, including reducing administrative burden through measure simplification, facilitating data sharing through improved interoperability, and increasing investments in behavioral health and the broader health care workforce. The NC Health Care Reform Executive Roundtable includes executive leadership from the NC Department of Health and Human Services, health plans, health systems, and primary care associations, among others.
• Listening Sessions & Presentations
• Duke-Margolis staff have engaged in 1:1 conversations with stakeholders to gather additional feedback, clarify specific action steps, and build momentum. Staff have also attended and presented at relevant stakeholder meetings around the state

Across all of the recent convenings and other engagement opportunities, the shared key priorities for multi-stakeholder collaboration are:

• Workforce Recruitment, Burnout, and Retention
• Identify ways to reduce administrative burden to help reduce burnout and increase retention.
• Build consensus around strategies to reduce variation in performance measures to relieve provider burden, improve our ability to measure and identify disparities, and support advanced primary care.
• Address persistent challenges with behavioral health workforce recruitment, retention, and behavioral health service availability.
• Data Collection, Sharing, and Tracking
• Invest in EHR interoperability and health information exchange, including through the NC Health Information Exchange, to strengthen the state’s data infrastructure.
• Target investments to build behavioral health data infrastructure.
• Health Equity Data
• Establish a vision for aligning the identification and measurement of disparities across racial and ethnic subgroups, as well as other patient populations.
• Identify priority health equity data, and support approaches to improve reliable collection and use of these data.
• Opportunities in NC for Value-Based Care
• Alongside the NC STC, leverage CMMI’s Making Care Primary Model, the 1115 Medicaid waiver renewal, and forthcoming Medicaid expansion in NC to facilitate equitable access to care, behavioral health integration, and multi-payer approaches to care reforms to enable more consistent access to value-based care supports.

Over the next few months, key action areas for the NC STC include:

• Measure Alignment
• Initiate alignment efforts across key, commonly used measures where health disparities exist (e.g., BP and A1c control, childhood immunizations, and other agreed-upon measures for behavioral health and maternal health) across racial and ethnic subgroups, as well as other patient populations.
• Establish standard definitions of racial and ethnic disparities and stratification of key aligned measures using existing race, ethnicity, and language (REL) data and initiate conversations to standardize the collection, storage, and sharing of REL and other health equity data.
• Data Sharing
• Identify opportunities to streamline data sharing and reporting formats to enable automated and standardized reporting, especially for aligned measures.
• Collaborate with the NC Health Information Exchange Authority and other stakeholders to advance data sharing efforts, including providing multi-payer aggregated data to providers.
• Alignment Across Other Payment Model Components
• Identify opportunities to tie performance incentives to aligned measures to further encourage health disparities reduction.
• Identify opportunities to align across other payment model components, such as attribution.

Each of these action areas represents foundational steps for implementing advanced primary care models, specifically in the case of Making Care Primary. In looking forward and advancing next steps outlined above, our team will work with stakeholders to establish clear goals and action items to support these efforts. We will engage patient and community organizations on advancing health equity data and measures, identify opportunities to support rural health, including through extending permanent telehealth policies enacted by NC DHHS in the commercial sector, prepare to effectively reach newly Medicaid-eligible individuals not already engaged in care, and identify opportunities to improve access to specialty providers given health workforce shortages.

Next quarterly newsletter coming in the winter!

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In these discussions, “alignment” is defined to mean the application of evidence and experience to assess and identify measures, administrative components, and data that would be impactful and practical for potential use to improve performance in the provision of value-based health care. These measures, components, and data concepts, combined with evidence, will be made available to the public as a resource for consideration and use by any interested stakeholders to further the Workgroup’s goals of reducing complexity for clinicians and advancing high-quality care for all patients.