Healthcare Analytics for North Carolina Hospitals and Clinics

North Carolina's 130+ acute care hospitals operate across one of the most geographically diverse states in the South — from the Research Triangle's sophisticated academic medical center market (Duke University Health System, UNC Health) to the Appalachian mountain communities of Western North Carolina, where Atrium Health (now Advocate Health after merger with Aurora) and Carilion-adjacent systems serve rural populations with among the highest opioid overdose rates and lowest physician-to-patient ratios in the country. Novant Health, WakeMed, and ECU Health (formerly Vidant Health) serve mid-size markets that sit between these extremes — sophisticated enough to require enterprise analytics, but not large enough to build and maintain dedicated data science teams at every facility.

North Carolina's Medicaid managed care transformation — which moved 1.7 million beneficiaries from a legacy fee-for-service system into contracts with Healthy Blue (BCBS NC), WellCare, UnitedHealthcare, AmeriHealth Caritas, and Carolina Complete Health — is the largest structural change to NC healthcare reimbursement in a generation. Hospitals that previously billed Medicaid fee-for-service directly now must manage MCO contract performance metrics, encounter data submission to each plan, and quality measure tracking against five distinct performance frameworks simultaneously. The 2023 Medicaid expansion added another 600,000+ newly insured adults who are now being attributed to managed care plans for the first time.

NC Medicaid Managed Care — administered by the NC Department of Health and Human Services (NCDHHS) — operates through five Standard Plans: Healthy Blue (BCBS NC), WellCare of NC, UnitedHealthcare, AmeriHealth Caritas NC, and Carolina Complete Health (Centene). NCDHHS requires Standard Plans to report HEDIS quality measures and access to care metrics; these flow down to contracted hospital and physician group reporting obligations. NC Medicaid also uses a Tailored Plans model for beneficiaries with complex behavioral health, intellectual/developmental disability, and traumatic brain injury needs — adding specialized reporting requirements for hospitals serving these populations.

North Carolina hospitals participate in CMS's HRRP, HVBP, and MIPS programs in parallel with NCDHHS managed care quality requirements. The NC Healthcare Quality Alliance provides public reporting benchmarks used by commercial payers in contract negotiations. The 2023 Medicaid expansion created new population health analytics obligations: NCDHHS tracks expansion population health outcomes as part of its CMS waiver commitments, requiring hospitals to support aggregate quality data submission for this newly insured cohort.