Shifting to Whole-Person Care While Fighting a Pandemic: A Q&A With Mandy K. Cohen, MD, MPH

Am J Manag Care. 2020;26(8):325-326. https://doi.org/10.37765/ajmc.2020.44068

AJMC^®: On July 2, North Carolina’s governor signed into law the state’s plan to move to Medicaid managed care, which I know you’ve been working on for a number of years. What will be different about this managed care plan for Medicaid compared with what other states have done?

Mandy Cohen: Well, you are right in saying we have been working on our Medicaid implementation for a number of years, and I think that we’ve gotten some national recognition for trying to use this opportunity moment of change for our Medicaid program and think through how can we layer on the kinds of new innovation that I think can propel the Medicaid program forward. So one of them is about investing in primary care, value-based payment models, but also, importantly, connecting people to care to the integration of social, physical, and behavioral health—so that payer alignment to get to some of the things that are outside of the traditional medical sphere.

AJMC^®: Is NCCARE360 one of those pieces that you mentioned?

Cohen: No—these are all interlinked pieces. So, NCCARE360 is certainly a very important piece of infrastructure for our state to allow us to break down the silos between health and the health care system and our community services, or the human services. NCCARE360 operates independently from Medicaid, but I think it does help us create the foundation to layer on these other initiatives as we move to managed care. NCCARE360 is the first statewide platform that allows for closed-loop referral between health care systems and the community. So we have it now statewide and we’re the first to be statewide and finished that implementation 6 months early; because of COVID-19 [coronavirus disease 2019], we sped up that implementation. It is a platform that allows for shared information between health and human services and it’s really never existed before. It’s not just a database of providers of community-based services, but it is a sharing of information. I’m a physician by training; just as I would have referred someone to a cardiologist, I can now refer them to one of these community-based organizations and we can actually share information so that I actually know as a doctor, did my patient get that resource, whether it was help with employment or transportation or food or housing or what have you. We’re really excited about it. It is part of what we will use in managed care. But we sped that along to help us as a critical tool to respond to COVID-19.

AJMC^®: Can you talk a little bit more about the value-based arrangements in the managed care program that will start next year, in terms of linking the services that were outside of traditional fee-for-service systems before, like substance use and behavioral health?

Cohen: Can I take a step back from that question? I want to make sure I’m answering your question properly. So within our managed care plan to move forward, we do have a plan to move toward value-based payment arrangement and new advanced payment models.

Another part of the work is to integrate physical and behavioral health—so there’s no more carve-out for behavioral health. We have this whole-person focus. And then a third aspect of what we’re doing is to also pay for some of the “nontraditional” things that drive health but may live outside of the traditional medical sphere.

So there’s payment incentives and alignment, and it’s particularly focused around primary care. Then there’s the integration of physical and mental health, and then there’s the third leg of the stool, which is that these pilots pay for things [outside of the medical sphere]. I wasn’t sure which your question was referring to; it kind of referred to a few of those.

AJMC^®: The part about behavioral health specifically and substance use [disorder] so that there are no more carve-outs.

Cohen: Currently, the way North Carolina is structured is that our behavioral health payment system is sort of carved out separately and there is a separate payer. It’s a quasi–managed care, actually, already in North Carolina.…It’s not fully managed care,…but it does carve out mental health separately. And it was really important for us to bring all of this together so that a Medicaid beneficiary would have an insurance card that will allow for the full spectrum of care that they need, physical health and mental health. So we have a plan to do both so that when we launch managed care for our first phase of populations, which is generally our moms and our kids, that product will integrate physical and mental health for our moms and kids. Then we have our folks who have more serious mental health, behavioral health, substance use needs, and they’re going to be in a second wave of moving into managed care. And they are largely going to be cared for and paid for by another entity, but also in that holistic way that brings together physical and behavioral health. [It’s] really important for us to have 1 payer that looks over both physical and behavioral health because I think it’s so important to get that close coordination, collaboration, between the 2 sides of things. And that took a lot of effort to bring those payers and to bring that benefit together into 1 payer. And so we’re looking forward to implementing that, although we are still a couple of years away. Managed care is intended to launch in 2021. And then the second phase of integration into managed care for our more severe folks who have more serious mental illness doesn’t happen until probably 2022, although we have not defined that date yet.

AJMC^®: That part that you just referred to, is that the Healthy Opportunities pilots that were supposed to start this year, but COVID-19 [delayed them] a little bit, or is that something else?

Cohen: That’s the third part. That’s our Healthy Opportunities, or our way of talking about the social determinants of health, or the nonmedical drivers of health. So that is a separate pilot. So we have all the integration of launching managed care, right, how everyone gets their traditional physical health and mental health coverage, so that’s what I was just referring to. In addition, CMS gave us the flexibility in a waiver to run a pilot to say, How can we use Medicaid dollars to think about paying for things that are not traditional health care? And that pilot has gotten a lot of national attention. We were one of the first to get this kind of flexibility and approval from CMS. When the Trump administration approved it, they called it groundbreaking, and I agree, and we are excited to get started with it. It was very much linked to our start of managed care, so it will coincide with the launch of managed care in that the state will have the ability to cover additional services that Medicaid doesn’t traditionally cover—things like the ability to help folks apply for food assistance, for the [Supplemental Nutrition Assistance Program] or the [Women, Infants, and Children] program. Or if a child has asthma, to pay for home modification; if they need to rip up their carpet and get a new floor surface, we can pay for that. There are a number of additional services that CMS allowed us to pursue, and we spent a lot of time defining what those were and creating the policies behind all of that and how we were going to structure it. And so now we’re getting ready to select where those pilots will be, and once we launch managed care, we can get into those pilots as well.

AJMC^®: Looking at those social determinants of health, your department picked 5 domains, correct? Housing, which you mentioned; food, which you mentioned; and is it also transportation, employment, and what you call interpersonal safety or toxic stress?

Cohen:Correct.

AJMC^®: So I was thinking, given what we’ve seen the past couple of months in discussions around building racial equity in health care and other social areas in the wake of the Minneapolis killing [of George Floyd], can you describe some real-world examples of how connections would be made in a medical setting in helping with interpersonal safety and toxic stress?

Cohen: Sure—like I said, that is some of the work that doesn’t need to wait for managed care. Managed care is just a mechanism for payment. What we want to do is make sure that we’re paying for the things that actually drive people’s health. And we can do that right now, and we are. We’re integrating them into the work that we’re doing to respond to and recover from COVID-19. One of the examples of that is this investment from the state, as well as the private sector, in this statewide shared tool, NCCARE360, that helps us pair people with the kinds of resources they may need. And we’re particularly wanting to target resources, as we build up our resources, into our historically marginalized populations. We know that COVID-19 has hit our Latinx, Hispanic, as well as our African American communities very hard, and we are working hard to invest in that. As we have been able to get some additional dollars from the federal and state government to assist with response and recovery, we are very much targeting that to community-based organizations that we can then link into our NCCARE360 network so that we can get a whole spectrum of coordination as we do this work to respond, whether someone needs transportation to get testing for COVID-19, or whether they need isolation supports, or they need some stable housing in order to be able to stay isolated, or they need food delivered while they are quarantined. We have a mechanism to now coordinate those activities as well as the new funds from the federal and the state government to respond to this to help with some of those isolation support resources.

AJMC^®: Do you also see ways in which NCCARE360, without having to wait for the full implementation of managed care, would be used as your state moves forward, for instance, when kids go back to school? How would that help students and families adjust in this crazy time?

Cohen: Ultimately, that is our vision: that wherever families may need assistance, whether they walk into a clinic, or they walk into an employment office, or they walk into a school, that we would have a way to connect them in to potential services that they may need. I think we have started largely in the health care space and in the community space and haven’t yet been able to link to our education partners, but it’s very much on our radar to be able to do. And look, schools have a lot on their plate right now, to prepare for the plan we announced [recently], which is to bring folks back for a modified in-person classroom experience for our K-12 public schools. They have a lot of work to do. We want to make sure that we are prioritizing and getting things to them when they need it. I think we will hope to bring our education partners into that platform, but first, better get [children] back to school with all the safety protocols, so we’re focused on that.

AJMC^®: Turning back to Medicaid, can you give an update on Medicaid expansion and also work requirements? You’ve noted many times in your public speeches how your state is a purple state. Do you think the pandemic will have an effect on either of those 2 things?

Cohen: Well, yes, and unfortunately, North Carolina has not expanded Medicaid. I think that has been a mistake. I’ve been very vocal about that. I think that should have been done years ago. And it is actually a black eye for North Carolina that we do not have Medicaid expansion. I think it has limited our ability to be prepared for COVID-19. I think folks have chronic diseases that are not as well controlled as if they had access to care. I think that’s well known. And when I think about coverage for testing, as well as the other medical care that comes along with it, we have a higher uninsured rate here, and it’s really unfortunate. We’re really working hard, despite the fact that we don’t have Medicaid expansion. The governor and I continue to say that it is needed. It is a critical tool. And it is something where we don’t have to invest any state dollars…we would raise that state share from our hospitals and our managed care companies. I think it is something we should have moved forward with and the governor will continue to press on it, and I’m sure it will be a topic of the election as the governor is up for reelection, as are a number of members of our general assembly, this fall. I think we will be having a statewide conversation of why haven’t we moved forward with this very important tool that could help more than half a million North Carolinians get access to insurance coverage, particularly in a moment of crisis.

AJMC^®: And even going beyond Medicaid expansion and looking a little bit outside North Carolina, I’m thinking about how the Supreme Court is reviewing the Affordable Care Act (ACA). And then there are those individuals who are covered not even by Medicaid expansion or insurance, and they’re struggling with everything in terms of price, cost, and access to care. Looking forward in perhaps a post–COVID-19 era, what do you think the United States can do to solve this problem?

Cohen: Well, that’s a big question. I think the first thing we can do is not threaten the gains that we have made. Right? So first is, make sure that we can solidify the gains that we have made and not go backward. North Carolina has not even fully implemented the ACA with Medicaid expansion. We haven’t even seen the full impact of what the ACA could do if it was truly, fully implemented. And so I’d like to see, as a baseline, us not go backward. So thinking about taking the ACA away or taking away financial assistance for people to buy insurance on the exchange is completely going backward, and that is a wrong way to go. Do improvements that need to be made? Of course, absolutely. There are still access problems and equity problems. And so we need to keep moving forward. But I think first and foremost, we have to stop continuing to fight the battle to move backward and we have to really figure out what are the important parts of the ACA that need to be still implemented here, and then go from there.

AJMC^®: Is there anything else you want to say about managed care? Is anything left undone in terms of your idea of buying health and not buying health care?

Cohen: Well, I would say there’s a lot of work to do. I think the only other thing that I would mention is that we are learning lessons now as we are responding to COVID-19 that we’re going to need to incorporate as we move to managed care. Two things come to mind in particular, as I have watched COVID-19 have such a disproportionate impact on the Latinx and African American communities. I think as we transition to managed care, you’re going to see more from North Carolina around addressing health disparities in order to not just combat the pandemic, but to really have a rethink about how are we delivering on access to care for our historically marginalized communities. I think you’ll still see a continued focus on integrating physical behavior and social health as we move forward. And again, this is because to respond to COVID-19, it’s not just about care, or should I say, medical care. It is about that holistic picture of health. You can’t just think about hospital and [intensive care unit] care. Most people are going to be at home recovering from COVID-19, and how do we support them at home with food or transportation to medical appointments or making sure that there’s worker protection so their job is there for them when their health recovers? I think this is just even showing more of the cracks of needing to do even more in that space. And then the last [point] that I would add is about data. Data have been so critical to help us shape our policy decisions. And look, the data are not always perfect, and in fact can be quite challenging. We have very decentralized [systems], both the health care system and human services system. So gathering those data in a way that allows for actionable, scalable decisions is really hard. I think that you’re going to see more from us on how we create that infrastructure to allow for data to be shared and captured to allow for coordinated response efforts, whether it’s to a crisis or to implement improvements in the Medicaid program. I think that’s going to also be another theme that that you will see from us—so, disparity and thinking about how we respond to disparities; that whole-person care, that is so important; and then the data piece.

AJMC^®: Speaking of the data piece, do you have any concerns about the hospitals in your state changing how they report their information to HHS instead of the CDC? Will that have a real impact on what you do?

Cohen: There was a lot of confusion when that got rolled out. And consolidating the number of databases that our hospitals need to report to is a good thing. I think the issue is understanding what fields, what parameters, how do they want everyone to submit the data in a standardized way? And so there’s a lot of confusion. There are also a lot of new data elements. Because those data translate into resources that our state will get—for example, like remdesivir, getting our allocation of remdesivir here is very much dependent on that information submitted—and the way things got rolled out caused a lot of confusion. We’re sorting it through. I think it will be ultimately fine. I think we just need to understand how decisions are getting made. What is the clear guidance, and what do our hospitals need to do? I think our hospitals continue to report to our state directly, in addition to the federal government, so it really doesn’t change our reporting, but we work so closely with them. We want to make sure this goes as smoothly as possible, obviously, as we think about something like a finite resource like remdesivir for our whole state. Obviously, getting good data in so we can get that resource is really critical.

AJMC^®: One thing you did not mention is telehealth. In rural areas that it can be good, or it can be a challenge if people don’t have smartphones or connectivity, and CMS has changed some of the regulations about phone-only visits. Are you among the people who want telehealth to stay?

Cohen: Oh, absolutely. In fact, I hope in a couple of years, we’ll stop calling it telehealth—we’ll just call it health, and it’s just another way for you to access care. No one calls it “telebanking.” But I want that to become part of how we access care even outside a pandemic. Now, I think we’ve accelerated our implementation of it really quickly this year, and I think that is a good thing, although I think there are a lot of kinks to work out. How do we best still make sure that we’re delivering good medical care? What is the right periodicity of still doing in-person care, because I do think that is still very critical, but how do we supplement the in-person with telehealth and what does that mean? Is telehealth video? Is telehealth telephone? What does that look like? Are we doing remote monitoring? I think we have a lot to work through there. But I am definitely interested in seeing telehealth change. We’ve already extended our telehealth policies until the end of this calendar year, and I hope that the other payers in the commercial space will do the same.

AJMC^®: Lastly, I’ve been thinking about the attacks that public health officials have been under. Your colleagues in other states have resigned; smaller towns have seen their health officials being threatened. What words of advice do you have for public health staffers across the country working in a situation that’s unprecedented?

Cohen: Well, I would say that this is the hardest thing that I have done professionally. And this work is hard. It is relentless. It is a crisis and it feels like that every day. And so what I would say first and foremost is thank you to all of those other leaders who are doing the hard work. I would say stay true to the science, be a leader, stay the course of trying to understand the science and adjust to that. Always be in a learning mode that we could have new evidence, new data, new technology, new medicines at any moment, which is wonderful, and to incorporate that into our thinking as we go forward. And just hang in there and say this too shall pass. We will get through this. I think if we pull together as a country and follow the evidence-based guidelines of what we should do to slow the spread of this virus, we can get through this. But it’s going to take all of us—not just those health and public health leaders, but leaders from every industry, business leaders, entertainment leaders, sports leaders, all of the government leaders, and other elected officials—to pull together if we want to defeat the common enemy, which is this virus. The enemy is not each other. It’s not the people here, and we may all have different feelings about how strong we should be on certain things, but the enemy is the virus and let’s focus our attention on defeating that enemy together.