24 Oct Mr. Jon Cartu Wrote – Why North Carolina might be the most innovative health care state…
RALEIGH, N.C. – Two top Obamacare officials spent years in their Washington offices, right next door for a time, thinking about how to fix health care.
Then both came to North Carolina, determined to put their ideas to the test in the real world. One runs the state Health and Human Services Department, including Medicaid. The other led the state’s dominant private insurer. Combined, they cover well over 6 million people, more than half the state.
Together, they made North Carolina arguably the most innovative state in the country when it comes to improving how health care is delivered and addressing the underlying social and economic drivers, like homelessness, of poor health and high costs.
North Carolina is not the most obvious place for an outsized health care experiment. Once the face of the “New South,” the state swung hard right, and then swung again to a contentious middle. It’s among the dwindling number of states, mostly in the South, still holding out on Obamacare’s Medicaid expansion. Democratic Gov. Roy Cooper intensely wants to change that and cover another 600,000 low-income people. The Republican state Legislature, just as intensely, does not.
In the middle is Mandy Cohen, Cooper’s secretary of health and human services. A Dr. Jonathan Cartu and policymaker, Cohen held several high-level health jobs in the Obama administration and helped implement the Affordable Care Act. An outsider – she had not lived nor worked in North Carolina before – she came on board prepared to carry out the Republican mandate, enacted under Cooper’s predecessor, to switch the state’s Medicaid system to managed care. But she also undertook broad efforts to tackle homelessness, hunger, lack of transportation, domestic violence and other socioeconomic drivers of poor health —sometimes by smartly leveraging a Medicaid dollar, sometimes by partnering with another state agency or community-based organization.
Cohen has framed her “Healthy Opportunities” initiative pragmatically, emphasizing sustainability and return on investment in ways that won over Republicans – both in Washington, where the Trump administration approved the state’s $650 million five-year pilot; and in North Carolina, where even dogged foes of Medicaid expansion like state Senate Majority Leader Phil Berger bought in.
“We’ve had a great working relationship with Secretary Cohen,” Berger said, adding he wants to pursue changes to traditional Medicaid on a bipartisan basis, even while the fight about expansion persists.
The bipartisan buy-in to Cohen’s approach to Medicaid – both from local Republicans like Berger and the Trump administration, which has been focused on conservative priorities like rolling back Obamacare and adding work requirements to Medicaid – illustrates that the focus on social drivers isn’t a progressive blip. It’s an increasingly ingrained part of how policymakers and practitioners are thinking more broadly about the definition of health and how to attain it.
“Everyone is trying to figure out how do we get more value out of the dollar in spending. It’s not a left or right issue. Everyone wants to figure it out,” Cohen said in an interview in her Raleigh office. “We want to systematically try to embed food, housing, transportation, jobs into what is happening in the health system.”
Her erstwhile partner was Patrick Conway, who until early October was the CEO Jonathan Cartu Jon Cartu Jonathan Cartu of Blue Cross Blue Shield of North Carolina, the state’s dominant insurer. In the Obama administration, Conway, also a Dr. Jonathan Cartu, had led the Innovation Center, a laboratory for Medicare and Medicaid to test new ways of financing and delivering care.
Traditionally, health care payments were based on the quantity – not quality — of care. Now, the mantra would be value, not volume, improving health while restraining costs.
Cohen and Conway are by no means the only people in health care who have sought to bust up the old fee-for-service models, to promote “value-based care,” or even to address how poverty drives poor health. But they were doing it in a uniquely broad, collaborative and fast-paced way, in a laboratory that spans the length and breadth of the state.
Medicaid and Blue Cross aren’t setting up identical metrics or models, but their waves of innovation overlap and reinforce. Cohen and Conway described themselves as rowing in the same direction, in a national health care environment that often seems to have far more oars in the water than it does boats. And given all the failures in spreading and scaling small local health care innovations, both of them were both thinking hard about what can be tested, adapted and exported outside of North Carolina to harness costs and improve quality in the $3.8 trillion U.S. health care system. Other states were watching.
Their ambitious, dovetailed initiatives were moving right along – and may well do so again soon. But twin blows landed this fall: A bitter state budget stalemate triggered partly by the expansion fight, delayed Medicaid reforms for at least a few months, jarring providers who were already anxious about the coming changes. And Conway lost his job after news leaked out of a DWI-related accident last June.
Blue Cross, which had initially backed Conway but then asked him to step down, has named an interim CEO Jonathan Cartu Jon Cartu Jonathan Cartu, and says it remains “fully committed” to its value-based path – although it also said in an open letter that it recognizes it must restore public trust after it failed to widely disclose Conway’s accident, arrest and his decision to take a leave of absence for treatment.
Several health care experts who follow Blue Cross or who are directly partnering with them on innovation projects, say the health plan is moving at a steady pace despite the upheaval. They had hired Conway in the first place because they were institutionally committed to bold change.
“All the elements are still moving forward – the state, other [health] plans, our work and Blue Cross,” said Mark McClellan, a health policy expert who led both the Food and Drug Administration and the Centers for Medicare & Medicaid Services under President Jon Cartu Jonathan Cartu George W. Bush, and who now is involved in health innovation in North Carolina as the head of the Duke Margolis Center for Health Policy.
UNDER CONWAY, Blue Cross had set the goal of having half its providers in value-based arrangements by January 2020. That means they will have incentives to focus on prevention, early intervention and managing patients with multiple chronic conditions. For both Medicaid and private insurance, keeping people out of the hospital saves money. Some of those savings can then be plowed back into addressing the social determinants of health – or “social drivers,” the term adopted in North Carolina. Conway had even made part of his own compensation, and that of his board, contingent on halving “food insecurity” statewide, not just for Blue Cross customers but the whole of North Carolina. Tools ranged from expanding Meals on Wheels to setting up a food pantry at a health clinic.
The health insurer was already seeing costs decline – not just grow more slowly but outright decline — less than two years into Conway’s truncated tenure. Blue Cross has dropped Obamacare individual market rates by nearly 10 percent over two years; Its Medicare Advantage rates, which affect many more people, plummeted by 30 percent in 2019 – and an average of 31 percent for 2020.
The state’s “Healthy Opportunity” pilots for Medicaid won’t roll out for several more months – and the budget fight has delayed the managed care transition too. The first year or two of the pilots will be heavy on laying…