Category: Community and Economic Development

Decreasing Cost and Increasing Quality: Value-Based Care Could Improve Communities

Co-Author: David Brown

According to the America’s Health Rankings by United Healthcare, North Carolina ranks 33rd in the country. As the ncIMPACT Initiative works alongside North Carolina stakeholders to solve complex problems, we increasingly hear concerns about how the state’s health outcomes affect community economic vitality. It is important to fit these conversations into the context of the changing health systems around us. As a patient, citizen, and community member, you may hear a repetitive term in this context: value-based care. What is it? What solutions does it promise, and what potential problems could it cause?


What is Value-Based Care?

In a granular sense, value-based care refers to health care programs based on incentives: care providers should have a financial stake in basing their care on patient outcomes rather than the number of tests, procedures, or other interventions (sometimes called volume-based care). In the case of Medicare, where the transition to value-based care is occurring most prominently, the federal government hopes that aligning provider reimbursements more closely to health outcomes will ultimately result in better care for individuals, better health for populations, and lower costs for everyone. Other valued-based reimbursement programs administered by the federal government include the Skilled Nursing Facility Value- Based Purchasing Program and the Home Health Value-Based Purchasing Model. This is part of a steady transition toward value-based care at the national level.


The Challenge of Health Costs

Everyone knows – often from experience – that health care can be costly. Some drivers of health care costs are obvious: investments in highly trained personnel and highly specialized equipment; the chronic nature of some diseases; and the willingness to spend almost any amount to prolong life and avoid pain. Little can be done about these cost drivers in our current system. However, much can be done to control costs by incentivizing preventive care, minimizing complications from chronic diseases, modernizing medical record-keeping to avoid unnecessary tests and procedures, and treating diseases and other ailments that tend to occur together as a single health problem, rather than as multiple.

Transitioning to a system where health outcomes are prioritized over the number of appointments and procedures makes intuitive sense, but there are pitfalls to avoid on the road to value-based care. Measuring health outcomes is complicated and lacks an agreed-upon methodology across providers. Further, a system that dis-incentivizes proliferating appointments and tests runs the risk of denying aggressive care to patients for whom it may be appropriate. In addition, there may be a long learning curve as everyone from major hospitals and insurers to small private practices adjusts to the new world of value-based care. Finally, any change that increases reporting requirements is likely to divert providers’ time away from more patient-focused tasks.

Further, hand-offs between specialists as part of a comprehensive care plan are more likely to be successful than if the patient has to seek out each provider on his own. The ultimate goal of improved health means fewer hospital stays and, in the case of a Medicare or Medicaid recipient, lower costs for the government. And if provider reimbursements are tied to improved health, rather than the number of interventions, the incentives for the provider might be higher for patients with a higher likelihood of improved health outcomes.


The Potential for a Promising Response: NCCARE 360

Advanced medical record keeping will become increasingly important with the move to value-based care. NCCARE 360 is a new statewide coordinated care effort that will electronically track, connect, and refer patients through an accountable care  network. This is a person-centered approach in which community members and providers in North Carolina will have access to:

  • A statewide resource directory
  • A community resource repository
  • A referral platform

Experts have recently established that while around 20% of health determinants are around access to healthcare, the other 80% are referred to as the Social Determinants of Health (SDOH). NCCARE 360 will allow for a team of providers and social organizations to track health outcomes of a patient together, with a comprehensive care plan that works in real time. Not only will the patient be a part of an accountable care community, they will also have access to services not typically associated with medical care: housing services, access to healthy foods, domestic violence services, and other SDOH resources.

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The promise of cost savings, greater efficiency, and better health outcomes will speed the adoption of value-based care in the coming years, as will legislation and regulations that require it. But providers and patients alike will need to be vigilant to ensure that the dollar-related outcomes are not prioritized over those related to patient health and well-being. NCCARE 360 gives an opportunity to impact health outcomes from a person-centered, community approach, creating accountability. NCCARE 360 will be implemented in every county in North Carolina by the end of 2020.


For more information, visit:


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Sticky Floors Impede Economic Mobility in North Carolina

The ncIMPACT Initiative recently completed a project examining poverty in Forsyth County for the Kate B. Reynolds Charitable Trust. Our focus quickly narrowed to the related issue of economic mobility – the ability of low-income Forsyth residents to significantly change their income or wealth over their lifetimes or the generations that follow. Of course, such examinations of economic mobility are inextricably tied to measures of an economy’s inclusiveness.

At the differing levels of city, county and country, global voices are increasingly raising important questions about the adequacy of old economic productivity measures to tell us what we need to know about the inclusiveness of economies. Think tanks and other advocates increasingly point out that commonly used measures, such as Gross Domestic Product, for instance, fail to consider the inequalities that lie beneath usual measures of well-being.

We found those critiques useful as we did our work in Forsyth County. The economy is transitioning from its historical reliance on tobacco and textiles, and the county is creating an impressive number of new economy jobs. However, a significant percentage of the local labor force does not have the skills required for this new economy. ncIMPACT’s research revealed that, for too many Forsyth County residents, the barriers to jobs that pay a living wage seem insurmountable. In essence, the local economy is not inclusive.

One of the ways in which economic mobility typically occurs is through advancing one’s educational status. Although our study found a clear desire for more education and training opportunities, barriers remain. Participants express the needs that must be met for this to happen. The most common need, expressed by respondents at a rate of 60%, is affordable education supports (e.g. transportation, childcare). Developing skills for available jobs often requires formal training and education. Providing additional resources to those who need additional support for advancement is one way an economy can become more inclusive.

ncIMPACT is not the first group to notice that Forsyth County’s economic inclusion measures lag behind its economic growth and prosperity numbers. In 2017, the Brookings Institution evaluated the nation’s 100 largest metropolitan areas along three dimensions: growth, prosperity, and inclusion. Based on the indicators used and composite scores generated, the Winston-Salem metropolitan area ranked 79th for growth, 73rd for prosperity, and 85th for inclusion.

The authors of the Brookings report explain, “Inclusion indicators measure how the benefits of growth and prosperity in a metropolitan economy—specifically, changes in employment and income—are distributed among individuals. Inclusive growth enables more people to invest in their skills and to purchase more goods and services.”  Similarly, the Rockefeller Foundation recently defined an inclusive economy as one that provides expanded opportunities for a more broadly shared prosperity, especially for those facing the greatest barriers to advancing their well-being. Simply stated, an inclusive economy offers more opportunities for more people based on five interrelated characteristics:

  1. People are able to participate fully in economic life and have a meaningful say over their community’s future.
  2. True opportunities are available to enable upward mobility for all groups of people.
  3. The local economy produces enough goods and services to enable broad gains in well-being and opportunity.
  4. Individuals, communities, businesses, and governments have a sufficient degree of confidence in their future and an increased ability to predict the outcome of their economic decisions.
  5. Economic and social wealth is sustained over time, thus maintaining intergenerational well-being.

For more information on inclusive economies or ncIMPACT’s findings in Forsyth County, see


Women in Construction

When more residents thrive, communities thrive.

Talent is essential for growth and competitiveness. When the potential of women is not fully harnessed, companies and communities lose out on skills, ideas, and perspectives that are critical for addressing challenges and maximizing new opportunities.

This reality is proving especially true in the construction sector for the greater Triangle industry, and communities are responding in innovative ways.

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Best Practices in Place-Based Grantmaking

Nathalie Santos is a student in the UNC School of Government’s Master of Public Administration program and a researcher for ncIMPACT. A graduate of Temple University,  she worked for a variety of education-focused nonprofits in the U.S. and Malaysia before coming to UNC. This is her first blog post for ncIMPACT. 

Much like Future Ready Communities, place-based grantmaking focuses on a location or place instead of a specific program or service. The Aspen Institute and Council on Foundations offer various strategies for place-based grantmaking that can also inform efforts toward ensuring a community is future-ready. Read on for their recommendations and best practices.

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What You Told Us in the ncIMPACT Planning Survey

We launched ncIMPACT in 2017 to help public officials in North Carolina navigate critical policy challenges across a wide range of topics, including health, education, economic development, criminal justice, public finance, and the environment. As we planned this new initiative, we wanted to hear from practitioners and other citizens about the most vexing policy issues in their community and in the state as a whole, and what we could do to help. As such, in January 2017 we drafted an online survey and distributed it with the assistance of various peer associations and a targeted Twitter campaign. Over the course of two months, we received 154 responses to our survey. Please read on for an analysis of our results.

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