Tim Gallagher, MPH, FACHE, PMP – The Value of NC Medicaid Managed Care

Today we talk with healthcare consultant, Tim Gallagher, who works with clients that serve the uninsured and underinsured. He counsels in navigating emerging models of care, leveraging better system solutions, tying into public sector funding, and forming value-based partnerships. Tim’s work in the NC Medicaid Managed Care Transformation efforts have placed him at the forefront of navigating a new care model in this state.

Tim Gallagher, welcome to the Move to Value podcast.

Thanks, Thomas. Glad to be here.

So, Tim, it, it seems like you’ve got a varied background. You’ve done a lot of really cool stuff. So can you tell me a little bit about that background in healthcare and how you became involved in Medicaid?

Sure. After college, I actually started helping some local physicians figure out how to build their claims electronically. There was a CPA who had a practice full of physicians and there were requirements for billing the federal programs like Medicare. Physicians were actually required to start submitting their claims online before everything had been paper.

So that was like 30 years ago, now as it turns out, and I made a career out of that healthcare revenue cycle, all of my strategy work has involved how we pay for things and sometimes it was more public sector focused like Medicaid or Medicare or Veterans health and sometimes it was commercial and private pay.

So can you tell us the story of the Medicaid transformation efforts in North Carolina?

Sure. I became exposed probably a 10 years ago as I was volunteering in the free clinics in and around the Winston Salem area and they were concerned about how the impact of Medicaid expansion might have on their operations. Much like the Affordable Care Act in 2010 diminished the need for uninsured to seek access in free clinics, they thought Medicaid expansion would also diminish their demand.

And so, from that perspective, I watched the state roll out a whole bunch of things. At the same time, my family was actually transitioning our daughter who has IDD intellectual and developmental disabilities and we were transitioning her out of, you know, school based supports into whatever was next. Alex qualifies for various benefits under Medicaid after she turned 18. And so we were unpacking how best to translate her benefits into actual services. You could say we’re a card-carrying family on North Carolina Medicaid.

Outstanding. So, you get that first-hand experience, that’s I bet that was that’s very helpful when it came to really learning the pain points of what was involved with Medicaid. What opportunities are there for managed Medicaid to accelerate value-based care?

Yeah, the opportunities are really just beginning. There was a white paper that the state put out probably back in January of 2020 and they articulated what they thought was a glide path for getting more provider arrangements into what they call alternative payment models. And the first year they knew it was just going to be a baseline for value based contracting and the state then encouraged people to move providers mainly to move towards quality and value via care coordination payments and pay for reporting.

And we’re just now getting into the fun part of like pay for performance and arrangements that allow meaningful differences in compensation in terms of higher quality provider groups. If you recall, only about 1.6 of the 2.2 million eligible for Medicaid transitioned in to managed Medicaid initially and Medicaid expansion and tailored plans this summer, the number has you know continued to increase. So Medicaid not only is rolling out value based, but more people are moving into the system. I would say today there’s about two million within the standard plans out of a 2.9 million who are the total population receiving Medicaid benefits.

What do you see as information that providers will need to know but aren’t asking or don’t know what they don’t know. We’ve talked about this before, you know, not knowing can be scary. But if you don’t know what you don’t know, then you’re blissfully happy. Can you, can you tell us what they need to know?

Yeah. I think the big thing is, is Medicaid’s mainly a temporary status. For example, when the Medicaid patient turns 65, they’re become a Medicare patient. Or when a Medicaid patient, you know, gets a job and gets employer coverage, they become an insured patient. Children also represent 45% of the total enrollees, and they’re not always children, right?

So people qualify for Medicaid during specific seasons within their lives, and that is not an indefinite season. So when I think about Medicaid, it’s really about solving it together. I mean, Medicaid right now represents 27% of our total residents within the state. You add in the uninsured, that’s about another 10.7%. And you’re talking about a real big group of people that are sitting next to your kids in school or driving across town in the same city streets and often functioning as frontline workers serving restaurants or grocery stores or hairdressers or yard service. So, they’re they’re people and they’re in relationship with us already.

Tim, I know you’ve done a lot of work with federally qualified health centers. Can you tell us a little bit about FQHC’s and how these organizations will benefit from managed Medicaid?

Sure. FQHC’s or federally qualified healthcare centers are obligated to care for all patients regardless of their insurance status or ability to pay. They’re only like one out of three providers like that. I think they’re the jails and the public’s health services, so Indian tribal and so there’s very few organizations like them. They have been seen as desirable for Medicaid patients because they have to treat anybody that comes in. Medicaid’s always been considered a good payer. It’s not like they’re a private practice that restricts the number of Medicaid patients they’ll see. Hence, Medicaid expansion not only offers FQHCS the prospect of serving additional patients under expansion, but it also converts people that are being seen for free as a paying patient and it improves their revenue situation.

And how will this expansion improve the Health Equity in our communities and enhance the efforts of the community health worker and social workers?

Yeah, equity is a is a big part of, you know certainly the FQHCS, but anybody serving in marginalized communities, equity and medical research is really an exciting area for me. We were fortunate to have a medical diagnosis for our own child because of because of DNA testing. And that helped her qualify for compassion allowances, which were a way to quickly benefit, you know, identify diseases and other medical conditions that by definition meet Social Security standards for disability benefits. Yet today I’m working with people who are being prescribed drugs which have never yet been tested on folks like themselves. And that’s just hard for me to believe in this day and age. If we’re getting more diverse populations to participate in clinical trials as a goal, then asking the providers serving within historically disinvested communities seems to be the pathway for that enrollment. And those providers will benefit by leveraging community health workers, social workers, people who are lifted out of those communities themselves to be part of that change.

And do you think that Medicaid, will do what it’s supposed to be doing, such as enhancing public health efforts and identifying and addressing social determinants of health to improve the health of the enrollees?

Yeah, I love some of the ideas articulated, especially under Healthy Opportunity Pilots. North Carolina’s current 1115 waiver expires on October 31st of this year and NCDHHS has already requested the ability to expand the three healthy Opportunity Pilots statewide and so that’s great and be a huge step in the right direction. There are also some waiver benefits in targeting Justice involved or LTSS long term services and supports. My perspective is that we built up Medicaid to care for new constituent groups like the working poor and ambulatory folks who will be able to benefit in the state’s investment and the basic infrastructure that Medicaid provides. Although that’s not who Medicaid was initially designed to treat. And I remain critical of the programs that we frequently read about in the paper, be it mental health, foster care, IDD. And so, I wanted to mention that. But facilitating SDOH interventions for better individual outcomes doesn’t fall on healthcare alone. Healthcare can contribute and lead, especially when we’re addressing social health needs. Yet when you use the term public health, it’s important to understand there’s other people with aspects to take care of like clean water, limiting the spread of communicable diseases, various regulatory inspections from restaurants to tattoo parlors. And so there are everybody has a role including various community led organizations and they play an important role as does local employers and city leaders.

Can you describe for us what Medicaid was originally designed for? Who that population is?

Yeah, you know a large majority of them are people that don’t have means, right. And so that becomes seniors in nursing homes And so they can’t provide for long term care. And so, Medicaid steps in and pays for the long-term care. And there are other populations like our daughter that will be historically, or you know, over their life, they’re not able to get out of the season I mentioned. It’s not like they, they come on Medicaid when they’re pregnant and then after they have a successful delivery, they move off when they get back in the workforce or you know, and another means of coverage. And so, Medicaid, the way I see it, leverages its overall infrastructure to serve what we call the working poor or you know, people that qualified under the Affordable Care Act up to 138% of federal poverty level. And that’s great. That’s an apparatus that we can bolt on. But Medicaid really exists to take care of the people that have no other means of having their care taken.

Tim, what are some of the areas of opportunity for improved population health through Medicaid?

Yeah, one of my favorite areas, I think that I’m excited about is the new Community Health integration Codes. And so, the Centers for Medicare, Medicaid, CMS created 2 new what’s called HCPCS codes, their Health Common Procedural Code systems to describe community health integration services performed by certified or trained personnel under the general supervision of a billing practitioner. That’s a lot. Basically, what it says is if you’re referred into the community, they’ll help you navigate to find those social determinant interventions. The services require initial evaluation management visit at a physician’s office, typically an office visit and then community health integration would furnish monthly as medical necessity when the practitioner identifies the presence of a social determinant which interfere with the diagnosis or treatment. And the fact that they’re going to pay about $70.00 to basically a community health worker to help someone navigate the system that could potentially provide them supports during the month. That’s just an awesome, you know, mechanism that hasn’t existed before.

That’s great! So, Tim, you’re a healthcare consultant and I would like to know what advice you would provide to your clients as they seek to incorporate value-based care, new models of care and the technology that’s involved therein.

Yeah, that’s a that’s a tough question and it goes back to just humans. I think you got to work with people you trust, and you got to get started. I mean, there’ll be lessons to learn along the way, but what we’re doing needs to be done, and we’re the ones to do it. So, you can’t worry about the people you’re working with necessarily. You got to find people that are ethical and have competence, OK?

And so after that, just know that Medicaid gets a bad rap because some of their rules and policies just don’t make sense. And good people in the system get crushed by the burdens of following their rules and regulations. Good people can’t fix bad systems. That doesn’t mean we don’t try, and we don’t jump in with both feet. There’s just learnings and so there’s healthy opportunity or this community health integration, it’s all you know fixing what hasn’t been working that people have been waiting for

Outstanding! So, Tim, what questions haven’t I asked that you feel are important to this conversation?

We talk about Healthcare as a right in this country sometimes and the question is, is it is access to healthcare a right? And if it is, who pays for it? And I think a better question might be how society should organize itself to provide some of the basic services to community residents. And if you really believe that equal access and equity is a goal, then FQHC’s and free and charitable clinics are a pretty effective model compared to other higher cost settings. And so, asking somebody that’s really high cost to open a rural clinic, it might not be your best method. I mean, we all, to use an example, if we wanted to go out, you know, on Saturday night, we hire a neighborhood kid, right? We pay them 10 bucks an hour. That’s not recognized in healthcare. There’s got to be lower cost models to get people into the system cared for effectively. I mean we’re not going to leave the house and trust our children with somebody that can’t watch them, right? But it also doesn’t need to be regulated. Like we can figure out how to do this in a lower context. And I think those kind of questions, does it always have to be government and does it always have to be written down and put in the federal register and you know, over regulated. There has to be some mechanism to help everybody there. You know, people in the safety net are pretty smart. They know how to find things, be it food or transportation or jobs, and they certainly know how to find healthcare, even if they’re uninsured or they have Medicaid. So, we got to think about it more as a society. These people are here. They live among us. They need to be served. And so the question is that is how do we address it, not just like as Medicaid or Medicare, but like healthcare and human.

I wholeheartedly agree. Tim Gallagher, thank you for joining us today on the Move to Value podcast.

Yeah, glad to be here.