NCDHHS Secretary Mandy Cohen – NC CEO Forum 2018

NCDHHS Secretary Mandy Cohen – NC CEO Forum 2018

Governor Cooper is a genius and
had a coup for being able to woo our very first speaker from running policy
in Washington, DC to North Carolina Secretary Dr. Mandy Cohen was the chief
operating officer and chief of staff for the Centers for Medicare and Medicaid
Services through the turbulent health care reform years of the last several
years, helping manage Medicare, Medicaid and the Affordable Care Act through the
last several years and she came to North Carolina a year ago to be our Secretary
of Health and Human Services. For those of you who were here last year and
raised your hand, she gave a speech on her very third day in office, and looked
like a pro. Well now a whole year later she’s going to give us the scorecard for
how her organization did and perhaps maybe a State of the State of Health
address if you will. Secretary Cohen. Good morning. It’s great to be back. Thanks
Brian for that kind introduction and that’s right.
This forum one year ago was the very first speaking engagement that I did as
Secretary of Health and Human Services. I followed my boss the governor who spoke
right before me and it was the first time I had the chance to hear him speak
in public. Frankly it was the third time I’d ever
met him. First was at my interview and when he introduced me when I got
nominated and so he shared his vision for North Carolina, which is what brought
me here. And you will you likely hear him say it later today: He wants a North
Carolina that’s more educated, that’s healthier, that has more money in their
pockets, so everyone can live a more abundant and purposeful life. What a
fantastic vision. I was excited to sign up on his team and to make that a
reality here. But then the next line he said a year ago was and now let me
introduce Dr. Cohen to tell you exactly how we’re going to do that. And I thought
okay boss we haven’t really had a chance to sit down yet so I’m glad to be back a
year later to share a little bit more about what we’ve been working on over
the last year and it really is in service of the governor’s vision of that
better educated healthier more money in your pocket vision, so folks can live a
more abundant and purposeful life. And for me and many of you who have heard
me talk over the last year, you know that our focus at the department, and mine in
particular as the official who’s really focused on health for this state, is
thinking about well how do I use all of the dollars that we have in the state
the time the resources to truly buy health for the state of North Carolina?
Right. Step back and say okay I want the healthiest North Carolina we could
possibly get and so how do i buy that? Right. And for me that goes back to value.
How do we get the most quality for the dollars that we’re spending in value? And,
I wanted to start with the patient’s story about how I as a physician did not
bring a lot of value to a particular patient’s life and it has now shaped me
and how I think about decisions for the future. And then I’ll go into our
priorities. So I’m finishing training at Mass General Hospital in Boston. I’d
finished medical school and almost done with my residency training and I’m
seeing someone in my outpatient clinic. The young woman, she’s 24.
She has commercial insurance, she’s Blue Cross Blue Shield of Massachusetts
insurance. She’s a college student full time. She comes in with some vague
complaint she’s losing weight she’s just generally not feeling well.
Maybe she’s losing some of her hair. And you know, I’m – I’m feeling pretty good
about myself. I went to Yale for medical school, right? I’m thinking okay I’m gonna
ask her about her family history. I order some pretty expensive lab tests. I’m
really good at that. They all came back normal. I wasn’t exactly sure what was
going on with her. I see her a second time. I think okay maybe it’s
not anything easy like an anemia or something maybe it’s an autoimmune
disease. God forbid it’s a cancer. Start imaging her head her belly. Can’t find
the answer. Third time I’m seeing her, seven or eight
weeks into our relationship, she doesn’t look good.
And I’m talking it over with my preceptor. I’m still a resident I’m still
learning and I’m sort of asking my mentor you know, where do I go from here?
I’ve ordered a lot of tests. Now I’m thinking what specialist should I send
her to, right? I’m a primary care doctor maybe it’s time to bring in someone with
some specialty knowledge when my my nurse tech who had checked the patient
in comes over and says to us, I think you need to ask her if she has enough to
eat. And that was a moment that was really humbling for me. Embarrassing.
Really. Because I went eight weeks before asking her a really important question
about her health. Do you have enough to eat? And she didn’t eat for eight weeks
because of me. Because I was ordering expensive lab tests and expensive
imaging tests. But I wasn’t asking her some fundamental questions about her
health. And so you know that was a pivotal moment for me because I said wow
I really need to start thinking differently about what we’re doing here,
in every patient visit that I see in my clinic, in our hospital system in our
community, right? And so I’m so lucky to have this opportunity here in North
Carolina to really start to look at that big picture about that value. About how
are we putting our dollars together and for me I’m not gonna forget to ask that
question again. And so, I want to think about how, and we know there’s a lot
of really good evidence and science now about how we need to think about things
like unmet needs around food or transportation or housing, and how that
impacts someone’s overall health. Think about your own health, right? When you
think about what keeps you and makes you healthy do you think about all the time
you spend in your doctor’s office? do you think about your New resolutions? Did you go to the gym? What are you eating? Did you quit smoking? Right? Those are the things that make up your health. And so, as the official who thinks
about the health of North Carolina, I want to embed that into every decision
that we are making so let me show you how that plays out in our three
priorities that we’re focused on. First is a big transformation that’s happening
in our Medicaid program. Second is around the opioid crisis, and third is a focus
on early childhood. So first on our Medicaid program, as many of you know
we’re about to shift our Medicaid program which covers 2 million people in
the state, we’re about to shift it from a state administered program to one where
private insurance companies administer the program. And we’re the largest state
that has not yet moved to managed care. So we’re in a really good spot. We can
learn a lot from other states that have done it well, and even some who haven’t
done it that well. And so we’re excited about that opportunity but it really
gives us the the chance to take a look at our program and say are we really
buying health? We spend 13 billion dollars with a B every year on the
Medicaid program and are we really using our dollars to buy health? And so as you
look at that transformation we’ve been thinking about it in three domains and
three things that we really want to make sure that we’re doing. One is thinking
about the whole person and for me that means their physical health their mental
health and their unmet social needs potentially, and putting that all
together in one package for and for thinking about that person. Right now we
have a we have a siloed system where we we we pay for bills related to your
physical health over here in your mental health over here and it’s caused a
fracturing of the way we deliver care. But as a primary care doctor myself I
know that you don’t take off your hat on your physical health or your mental
health as you walk in my office. And we shouldn’t do that in the way we think
about how we pay for the care. So we really need to bring all of that
together the physical health mental health and the unmet social needs so you
will see that as we continue to move forward and we’ve been having very good
conversations on how to make that a reality in our law so we can take that
out in our program so a lot of a lot of agreement and and movement forward there the work to do. Second is needing a robust quality
strategy right I’ve talked about value I want quality for every dollar that we
spend and so that means holding all of us accountable from the state down to
the individual doctor, nurse, provider for the really important outcomes. And so, and
it’s also about how do we use, how we pay to drive towards that quality I bet
you’re gonna hear a bit about that from my my friend and colleague Patrick
Conway who’s sure thinking about that differently, and we want to align with a
lot of the work that’s happening in the Medicare space, where we think about
paying differently and using alternative payment models instead of paying piece
by piece by piece, really thinking again about that whole person as we as we move
through things. And then lastly you’ll see a big emphasis from from us on that
link between unmet social needs those the strain around food or housing or
transportation and healthcare. So a couple ways in which we’re doing that
one is don’t be like me we have to do, we have to do real screening. We have to ask
the question, right? My issue was my patient didn’t look like right someone
who ran out of food. She was a college student. She had Blue Cross insurance. She would look perfectly put together and I didn’t ask the question. But we have to
ask a question. And this isn’t just about asking the question of those who are in
the Medicaid program. We know that that in the commercial population as well
people with private insurance they also struggle with some of these things, so
we have to ask the question about health. So one is asking the question, and then
when we actually find out the answer we actually need to get people the resource
to navigate them to the resources that exist because they are there. They’re
there in our community. But we need to knit together our healthcare system and
those social services that are in the community. And then lastly, we need data.
We need data to know what works. If I invest in something related to food or
housing is it really giving me better health, right? Going back to that am i
buying health, am i getting value question. So you’ll see the Medicaid
program make a big investment on trying to build the evidence base for what to
what to really invest in. I’ll give you an example. Here in North Carolina at
Cone Health they piloted a program related to kids with really bad asthma.
When kids have really bad asthma they end up in the emergency room a lot. And
what Cone Health did instead of continuing to pay for those and treat
kids in the emergency room they went to their homes. They ripped up their carpet.
Put down new carpet and gave them an air filter. And guess what happened? Less
emergency room visits. Lower costs. Mom and Dad back at work. Kids at school.
How often in health care are we getting wins like that, right? When we can
actually spend less. Get better outcomes. Mom and Dad more productive at work. Kids learning at school, right? That’s what we want and so I want to build the evidence
base around buying carpet. So I want to use my Medicaid dollars to buy carpet
because I want to buy health. So that’s our Medicaid work and it’s a lot of
exciting stuff going on, and I know a lot of you in the room are engaged in that. So
thank you on the partnership for that, and for running fast with us to do to do
this work. Second let me mention the opioid crisis. It is something I spent a
lot of time on with my my colleague, Josh Stein, our Attorney General, focused on
this effort over the last year we’ve done a ton of work also many of you in the
room. We put together a coordinated action plan across the state. We had new
legislation passed, we’ve seen the number of prescriptions of opioids go down, but
a lot of work still to do. Too many folks are dying every single day. The number of
emergency room visits that we’re seeing for overdoses
is skyrocketing even with the fact that we have 50,000 doses of Naloxone that
were distributed at the end of last year. We’re still seeing the numbers go the
wrong way, and this isn’t magic. We actually have the science we have the
evidence we know what to do we just have to wake up every day and do it, right. So
that’s a lot of things right it’s not one thing and it’s not one thing in the
health care sector which is why we have that coordinated plan. It’s getting
people access to treatment but it’s also making sure we’re getting upstream and
doing the prevention work. It’s also getting the number of prescription
opioids down and then it’s also working with our law enforcement partners to
make sure we’re getting illegal heroin and fentanyl off the streets. So it’s a very big big job and like I said we need the continued effort and
continued energy to all work together on that that issue. And then third – let me
leave you with our third area of work which is really our focus for this
coming year. Similar to how we did the opioid work we’re thinking about how do
we do coordinated work to focus on early childhood – that’s zero to five in
particular age group. And our department touches the lives of children in so so
many ways it’s actually it’s incredible. We cover 1.5 million children’s lives. We
pay for half the births in the state we run the NC pre-k program the childcare
subsidy program. We run Child Protective Services and others, so we, at the
department, really need to think differently about how do we bring a lot
of those pieces together to do better for our families and for our kids. I’ve
been really moved and I hope you may hear over the next two days about some
some of the real interesting research about brain development between zero and
five I think that’s become very common now where we know that that zero to five
time is really when a lot of those neural pathways are getting laid,
and that it’s really important to make sure the kids are healthy and safe and
being nurtured and being read to and hearing language. But what’s really been
fascinating to me is the newer research I’ve been seeing about what happens to
children when they experience trauma. And what happens to your physiology and how
will your physiology actually changes for the rest of your life when you
experience trauma as a kid. And that can be anything from your parents getting
divorced to you actually having unfortunately abuse in the home or
seeing a parent with substance abuse disorder or being food insecure, right.
Any of those traumas actually makes your body act differently for the rest of
your life. There is really interesting research back at Mass General where I
trained they have a bariatric surgery clinic, right for those who are obese and
awaiting surgery. And they administered a survey asking about childhood trauma or
adverse childhood events to those who were awaiting bariatric surgery and 80%
of those awaiting bariatric surgery school had three or more childhood
traumas. 80% three or more childhood traumas. That made me think very
differently about my work as a primary care doctor, right. I’m trying to fix
diabetes and and get people to stop smoking and think about their their
weight and that connection to their blood pressure, right. And when I needed
to think about wow what happened to them as a kid and going way back upstream of
that, which makes me think about spending our time investing in our kids zero to
five. And so we are thinking about a coordinated approach across three
domains. One is around health goes back to that buying health are we getting
value for all that the dollars that we’re spending and really focus on
making sure kids are healthy during and developing well zero to five. But then
they have to also be safe and nurtured right. That goes to the brain development
and making sure that they’re getting that social
interaction, because we know they if you put a kid in a box with the healthiest
food and getting their flu shot but they’re sitting in a box and not talking
to anyone they’re not going to develop their brains in in the appropriate way.
So it’s really about that human social nurturing and interaction. And then
lastly are they learning and ready to succeed when they come to school? And
that we know there’s a lot of good evidence that’s not just being in pre-k
that’s being in pre-k with a really qualified teacher. It’s reading to your
kids at night but it’s also making sure kids aren’t coming to school hungry
because you can’t learn if you’re hungry. So all of those things are things that
we’re putting together in a coordinated plan, and again for me it’s not
necessarily about net new things but it’s about that coordination across all
of the things and the ways that we just touch children and families at the
department. So stay tuned for more on that and I’m a data, data gal so you’ll
see a lot more on how we’re trying to measure some of those things and really
drive improvement across the work that we do for early childhood. So that’s a
lot and I hope our picture over there captures my theme of value and buying
health are focused on our Medicaid program and making sure that we are
focused on that whole person, our opioid crisis, and really this is
about keeping that focus and energy on the work that we’re doing related to
opioids. And then lastly around early childhood and how do we focus all of the
ways in which we think about children across that continuum of health, nurtured,
learning, ready to succeed and how do we do better for all for the kids here in
North Carolina? Again, to go back to the governor’s mission statement, so that we
can build the North Carolina that’s more educated that’s healthier there’s more
money in their pocket so they can live an abundant and purposeful life. And I’m
not just kissing up to my boss. I think that’s a fantastic vision for our for
our for our state. I need all of your help to actually make that possible but
I’ve had a fantastic first year here thank you for
being a wonderful first place for me to be a year ago. I think, I hope you are
proud of some of the progress that we’re making across the state and just thank
you for the attention and the hard work.

Danny Hutson

2 thoughts on “NCDHHS Secretary Mandy Cohen – NC CEO Forum 2018

  1. Thank you, Secretary Cohen for your vision and commitment.  As a first time foster parent and an employee of DHHS, I respect and join you in your passion for the children of NC.  The opioid/illegal drug crisis has compounded the trauma too often experienced by this vulnerable population (children 0-5 years old).  I'm excited about the good work coming from your administration.


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