CMS' Boehler, NC Health Chief Cohen Talk Strategies at United States of Care Panel

Her patient, a young college student with commercial insurance, looked unwell and Mandy K. Cohen, MD, MPH, had spent 8 weeks running expensive tests trying to figure out what was wrong.

Finally, Cohen’s technician said, “I think you better ask her if she has enough to eat.”

Cohen, now the secretary of the Department of Health and Human Services in North Carolina, discovered that the student had just left an abusive relationship and was living out of her car. Cohen recounted the anecdote at a panel Monday during the inaugural convening of the United States of Care, the healthcare advocacy group launched earlier this year.

“It still stings,” said Cohen, a primary care doctor, speaking during a panel about state strategies to address costs and improve care, with a focus on social determinants of health (SDOH) and preventing disease. “I spent a lot of money and I didn’t make her one bit better.”

Cohen appeared on the panel with Adam Boehler, the CMS deputy administrator for Innovation and Quality and director of the Center for Medicare and Medicaid Innovation (CMMI), and was highlighting North Carolina’s 1115 waiver approval from CMS. The approval is for implementing the transition to Medicaid managed care and integrating physical health, behavioral health, and pharmacy benefits. The approval also has a component of SDOH, which Cohen and the state call “Healthy Opportunities.”

The moderator, Molly Coye, a former state health commissioner in New Jersey and California, and now with AVIA, a network of health systems, asked Cohen and Boehler to focus on how care is being transformed in terms of quality, access, cost-effectiveness, and “the nature of care itself.”

In addition, Cohen and Boehler talked about federal-state collaboration in pursuit of shared goals around value-based care, alternative payment models, and the challenge of convincing managed care organizations to accept 1-sided risk models.

In Medicaid, North Carolina is integrating physical and mental healthcare and is investing in primary care, Cohen said. The state is also focusing on value, not just in terms of the capitation environment but also by including alternative payment models, she said. This all falls under the idea of “buying health,” said Cohen, who has a $20 billion budget.

Boehler came to CMMI from the private sector, where he was the founder of Landmark Health; he initially refused the job. As someone with a private market perspective, he did not think much of government, but said he was swayed by “the ability to get things done without going through Congress for everything.”

CMS has 4 points they keep in mind when making decisions about value-based transformation, Boehler said: patients as consumers, providers as accountable entities, payment for outcomes, and prevention. The waiver in North Carolina connects with those 4 areas, he said.

“You prevent disease before it occurs,” said Boehler, who also said that doing the right thing by patients will more than pay for itself.

He also discussed the need for artificial intelligence in healthcare and moving heathcare to a base level of proficiency so that derived, predictive analytics can both improve care while lowering costs.

For Cohen, the state needs to have better data in order to know what the most effective interventions will be to improve health. For instance, they know that improving the home environments of children with asthma by removing old carpeting will keep them out of the emergency department, leading to better health at lower cost. That same information is not so readily apparent for women with high risk of poor maternal health, she said.

Both Cohen and Boehler discussed trying to persuade different stakeholders over to their point of view.

North Carolina is a purple state, said Cohen, with a GOP-led super majority in the legislature (one that will become a simple majority in January) and a Democratic governor. But even with deep policy differences over coverage, she said, there is bipartisan agreement on health and strengthening the Medicaid program and efficiency. Even the lawmakers opposed to Medicaid expansion recognize that there are problems with rural hospitals closing and that their constituents have been hard hit by the opioid crisis, she said, so she looks for alignment where she can.

Coye wanted to know how Boehler dealt with talking to providers and organizations about the idea of delegated risk.

To date, there hasn’t been the ability to take on delegation in Medicare, Boehler said. Some of it depends on size and for the single provider it is not appropriate, he said. In addition, many providers operate under the "churn and burn" model, slotting patients into 15-minute sessions, and when a patient with complex chronic needs comes in, they lose money. Shifting to outcomes and keeping patients out of the hospital will actually earn their practice more.

"Let's stop paying people based on an activity," he said. He also said the biggest issue with multiple different payment arrangements is that organizations do not fully commit to one, and that is the main problem with upside-only risk arrangements favored by some accountable care organizations.

Andy Slavitt, who headed CMS under the Obama administration and who launched United States of Care earlier this year, refused to let the panel end the session until they answered how they think they will bring the voice of the patient into their decision making over the next 5 years.

Cohen said that when the state had its initial Medicaid Transformation meeting, it had a patient family in the room because the state felt that they needed to hear from them first. She also said the governor's focus is on the health of its citizens, as opposed to the notion of "healthcare."

At CMS, Boehler said the administration wants to do what is right by patients first, as opposed to various stakeholders who may be unhappy with some of their decisions.