Advancing Health Care Transformation in North Carolina

Advancing Health Care Transformation in North Carolina


– Good morning, good morning everyone. Good morning, thank you
for being here today. I’m Mark McClellan, I’m the Director of the Duke-Margolis
Center for Health Policy. And on behalf of the Margolis Center I’d like to welcome all
of you to today’s meeting on Transforming Health
Care in North Carolina. It is great to see so many people, including many familiar
faces who are committed to improving North Carolina health care. I know many of you came from a ways away, we appreciate that. I know many of you are busy
with public commitments, many members of the legislature here. Thank you all for taking the time. And I also want to give my thanks to those of you who are joining us on our webcast today. For all of you who are on social media, it’ll be back up on the
screens in a little while. We are tweeting today
and if you wanna join in, our hashtag for the meeting is #transformnc. For those of you who are not familiar with the Duke-Margolis Center, We’re looking forward to
getting to know you better. We are a relatively new
university-wide program set up to address pressing
issues in health policy and health reform. Much of our work focuses on the national and global level, but we
think some of the best and most important opportunities
for improving health and reducing costs are right here at home. We are all here because
this is a very special time in North Carolina. Over the next few years,
the state is on track to implement a set of
collaborative healthcare reforms that are intended to support innovative, personalized, less costly health care that gets much better health outcomes for North Carolinians. There is a great foundation for this work. The state is home to
leading healthcare systems capable of delivering
state of the art care, innovative primary care practices, community health centers, and
rural healthcare providers who are working hard to
deliver excellent care at the lowest cost. These healthcare organizations are made up of committed professionals, physicians, nurses, pharmacists, other
clinicians and health workers. They’re working alongside
community organizations and consumer organizations
that are developing and implementing new approaches to addressing population health problems. We have an employer community, committed to doing more to
improve value in health care because it is so critical
to the future well-being of the state. And we have a strong
and growing biomedical and health tech innovation community. And as you’ll hear more,
in just a few minutes, we have leaders in state government on both sides of the aisle, who are taking major new
steps to support these efforts in the diverse communities
across North Carolina. So this is a great foundation. But at the same time, there’s an urgent need for transformation. We’re facing some real health
challenges in North Carolina. Despite all of these resources, and despite health care costs
that have continued to rise. North Carolinians are
experiencing stagnant or worsening population mortality rates, and large health disparities. The state ranks 33rd in the
nation in overall health. There are large differences
in health across the state with minority populations,
lower income individuals, and people living in rural areas experiencing particularly poor outcomes, and over one million North
Carolinians are uninsured. To address these challenges, the way that we pay for health
care is on track to change from a focus on volume of medical services to a focus on supporting
healthcare organizations, large and small, urban and rural, to deliver the care and
services that really matter for the health of each person. We have highlighted the
magnitude of this change in a newly released report in the Health Affairs Online blog. That’s available online, so Health Affairs North Carolina Healthcare Transformation. You’ll hear more today on the
coming shifts in Medicare, in Medicaid, and in commercial insurance, to pay for value and better outcomes, and not simply more services. This change is intended to support innovative ways to deliver care, innovative ways that are oriented towards preventing disease,
preventing costly complications, and using the best science and evidence to implement more convenient
and efficient ways to treat serious illnesses as well. All of this means supporting patients and getting more at the root causes of costly medical problems,
which can involve mental health, and addressing social
and community factors that drive high medical costs. Based on our estimates, by
2022, just a few years from now, the state is on track to shift from having around 30%
of medical payments today in modest versions of these so-called alternative payment models, to 70% or more of it’s health care payments through more advanced
alternative payment models. For comparison, a recent national survey showed that around 35% of payments were in these new approaches nationwide, and most of those were only modest shifts to pay for better care. So the scale and pace of what
is happening in North Carolina in the next few years, is unprecedented. It’s a bold statement that
the status quo of health is not nearly good enough here, that we are committed to doing better and that we’re not just talking about it, but we’re putting our money behind it. The shift in payments is
getting national attention but it’s only one part of
what’s really going on. It’s a means to an end. It’s one critical component
of a whole set of initiatives underway in North Carolina, to support healthcare
reform and transformation. Together these reforms in
the public and private sector aim to support better ways
of providing health care, especially for people
with serious illnesses, chronic disease, and limited means, and limited access to care in
many rural parts of the state. It’s a shared effort to make
real measurable progress toward better health and
better quality of life for the people of North Carolina. These changes will not be easy, so today we’ll hear from
a range of perspectives about what is happening
here and why it’s important. But it’s also about
understanding the challenges that lie ahead in making
these reforms successful, and identifying ways in which clinicians, employers, health plans, and all of us can work together to
overcome these challenges and make the most of
this unique opportunity. We know from prior
experience around the country that there are many
challenges in improving care and lowering cost, from data and access to healthcare providers,
defining synergies rather than conflicts among
the many programs underway. Today is about those
challenges and next steps. We wanna use the day to
identify further steps that our public and
private sectors can take to accelerate progress. So we look forward to your participation, your questions and comments, and opportunities to
connect with each other since we are all in this together. Our Duke-Margolis Center is committed to supporting these efforts, our faculty and staff are already involved along with many of these
collaborative efforts around the state, and with the support from the Gary and Mary
West Health Institute, and other foundations,
we’re expanding our work to support steps to improve care. As we make progress here,
in these unprecedented public and private sector steps
to make health care better, we think that there will
also be many valuable lessons for the rest of the country. If you’re interested in
partnering with our center on these opportunities,
please let our team know. We have many of our members and faculty here with us today. So let’s get started. To kick us off, it is my privilege to introduce Mandy Cohen, the Secretary of Health and Human
Services for North Carolina. Among many other
responsibilities as Secretary, she has lead efforts to
strengthen the Medicaid Program and other state programs
through value-based care partnerships and reforms, steps to address the
social drivers of health, and steps to create the supports needed to make it all work. Secretary Cohen, thanks for
starting our discussions today. (audience applauding) – Good morning. – [Audience] Good morning. – Well thank you Mark for
that kind introduction and also for your personal
leadership in this space. It has been so important. I think you all know
about Mark’s background and the service that he
had at the federal level, both at CMS and the FDA,
and the fact that he is here in North Carolina, both
as a national leader, but focused on the work here in the state is really important and powerful. He’s been an important
sounding board for me, and has helped us as we negotiate a lot of our work with
our federal partners. So it’s been a tremendous partnership, and so thank you, Mark, for
that and your leadership. And so, I wanted to start today
with the North Star, right? If we’re thinking about value, we’re thinking about where
do we wanna move this system, I think it really helps to ground us. And what are we ultimately shooting for? And as I think about that, as I am charged with the health and well-being of the state of North Carolina, I want to charge towards health, right? And so when I use this
phrase, buying health, it means I wanna turn all
of the levers at my disposal in partnership with you to buy health for the state of North Carolina. As Mark said, we have
growing budgets in this space and I wanna make sure that
we are targeting them all in a way that actually
drives us towards health, and not just health care. Many of you, I’ve given many speeches over the last two years,
being in North Carolina, have heard me talk about my patient, where I did everything wrong as a doctor in terms of driving her towards health. I saw a patient who I ordered
a lot of lab tests on, I did a CAT scan on. I knew her for eight or nine weeks, looking at her being very ill. I spent a lot of healthcare dollars before I actually got
to the fundamental root of what was going on with her, which was that she didn’t
have enough to eat. And it haunts me, still to this day, and it was what drives
me towards this mission of really driving health. And part of the reason that I didn’t get to that core of health for my patient, I hope it wasn’t because
I was a bad doctor, it certainly wasn’t because I didn’t have an expensive
education, ’cause I did, but, right, it was, it
was because the system was not set up to drive towards health. And I think that is what
we’re trying to get at here, is how do we use all of those levers. And I think it’s really important
moment in North Carolina. I think as Mark was
setting us up for this day in his conversation, is
that we have an opportunity here in North Carolina,
because of a number of factors. But I also think that North
Carolina is a microcosm of the nation, and I think
doing that work here, and this is hard, hard, hard work, and I’m gonna say that a lot of times. This isn’t something where
you snap your fingers and change happens. This is going to take a
concerted effort over many years to make these kinds of changes. But I think we have
some unique factors here that I think set us on
that path towards success. Now one of them is payer alignment. I think in the health affairs paper that Mark’s team laid out,
is that it’s pretty unusual to get this level of alignment between your commercial payers, where Medicare is heading, and now where Medicaid is heading. Obviously I’m gonna spend my
time talking about Medicaid, but I think the course of the day, I think I hope will show
you that there’s alignment. And when you can get
alignment among payers, it allows you to get more alignment among delivery systems, right? Because if the payers are all trying to ask for the same
things in a similar way, and driving towards that same goal, right, it helps folks that reorient to say, okay, these folks are asking
me for the same things as a hospital or a practice. We can make that change, and I
know where we are all headed, even though that change is hard. So I think that’s a really exciting place, and you’re gonna hear more about that. I also think that this moment of transitioning our Medicaid
program to managed care, the fact that it is
starting for the first time, we are the largest state that
hasn’t moved to managed care in the country, which
means we’re allowed to, we can learn a lot of lessons about how this went well in places and then where it fell short. And are there ways that we
can mitigate those shortfalls but run way faster to all the things that were working, and
scale them even quicker. And so, as I mentioned,
if we capture this moment here in North Carolina, I
think that it is really a model for the nation. The fact that we are a large state, that we have purple politics here, the fact that we have
rural and urban divides, that we are racially diverse, but also we have fantastic
medical institutions here that are able to be national leaders. I think this moment, and
North Carolina in particular, really is the national model
that folks are looking for. And it means it’s hard, right? It means we’re going first, and that always means that it is hard, and we’re gonna learn a lot of lessons, and we’ll need to make
course corrections over time. But, I think that it is, like I said, a really important moment. I’m glad that we are all here in this room to talk about that, but
it’s going to, like I said, be a journey here for all of us. I’m gonna keep coming
back to this last point, which is that the data piece and the cultural piece of this, I think, are the critical underlying factors that are going to determine
whether or not we’re successful. And so I’m gonna keep coming
back to the data pieces, and why data is so important, because I think if you’re
really gonna get to value, and you’re really gonna
drive these changes, you’re gonna need information
at the right time, in the right setting,
to actually drive folks to resources that are
gonna make them healthy. And so, I’ll keep coming back to that. And then I’ll come back to
this culture change piece, because it is different. Right now, as I said, when I’m a physician trying to take care of my patient, I was not set up for success
to drive towards health, and that means a very different use of both my time as a physician, the way the system is set up, and that takes a lot of culture change, and know everyone in this room who’ve ever been through
any sort of transition, whether it was an EHR
implementation in your system to a big disruptive change, knows that the culture piece
of this is so critical. So let me just talk a little bit about Medicaid’s move to value. And it is not just about payment changes, though that, I think, is an
important component of it. It is really about a suite of things that we are trying to
do in coordination here, the first one of which was
integrating behavioral health and physical health. As you know, right now
in the Medicaid program we pay for those in different ways, meaning we have different payers. The state pays for physical health, and have LME/MCOs paying
for mental health, and often that can cause a disconnect when it comes down to the clinician, and the patient, and who’s paying what, and how do we coordinate services. So one of the first things
that we wanted to tackle when we started looking at this work and how do we build towards
a healthier North Carolina, was really thinking about whole person, and that means not separating
out the physical health and the mental health. So as we move forward in this first phase of managed care for Medicaid for example, it’s really our moms and our kids, it’s 1.6 million beneficiaries
that will be moving to managed care over the next year. And if you think about moms, for example. Medicaid pays for half the births in the state of North Carolina. We know of a number of those folks. Mom’s gonna get post-partum
depression, right? Physical, mental health, want
that care to be coordinated, want mom to get healthy,
you want baby to be healthy, you’d make it to get the
best start in life, right? So those are the really important pieces so that when we launch into managed care we don’t have folks saying,
no, that’s your responsibility. Right, we have a quarterback
that’s gonna be responsible for the total behavioral
health and physical health. The second piece of the path here is about advanced medical homes, and that is really our commitment to investing in practice-based
care coordination. We know care coordination
is such a critical part to really winning in
the value piece, right? Making sure folks can navigate the complex healthcare
system that we have. But we are really putting a big bet down on getting local with
that care coordination, and wanting our clinician practices and our hospital systems to
be at the forefront of this. And so not having care coordination be on, at phone-based,
and sort of removed, but really be embedded
in where the patients are living, right? Because again, trying to
drive folks to health, I think takes a certain amount
of knowing the community and driving folks to the right resources. So again, in our advanced
medical home program, we are putting additional dollars to flow directly to practices, to do that care coordination, and I think that’s a
really big step forward. And I think, again, a huge,
huge data component here, right? Because it means care coordination, you have to be targeting your
high risk or rising risk folks to make sure that we’re keeping them out of the emergency room,
on their medications, getting to their appointments, but also driving to the other
resources that they need around housing and food and others. So that’s our medical homework
we’re very excited about, but also, again, a ton
of work to do there. Third is around the payment piece of it, and the value-based purchasing. And so we’re trying to
line up all the things to allow for folks to think
about alternative ways to get payment in order
for them to think about the whole person. If you’re gonna continue
to think about people piece, by piece, by
piece, in fee-for-service, you’re really never going to
be able to break out of that and think of the whole
person, I don’t think, and really think about health, right? ’cause you’re just thinking about pieces, and how many pieces can you
add together to make it work. We wanna really get to a place where folks can get the
incentives right, right? And be incentivized to do the right thing which is what folks
wanna do to begin with. They wanna keep folks healthy. So let’s pay for health. Let’s not pay for hospital admissions, let’s pay for health. And so, not that anyone’s
doing anything wrong by admitting folks to the hospital, we haven’t set up the system for success, and that’s where the
payment piece comes in. So we want folks to move to
alternative payment models and in the Medicaid program
we have some requirements about moving at least 50% of payments to value-based models by
the end of the third year, but my message this morning
is don’t wait, right? We know where commercial is going. Already, we’ve, and
you’re gonna hear later from Patrick Conway on
what folks are doing in the Blue Cross space. We know where commercial’s going. Many hospital systems and health systems already have ACO partnerships
(clears throat) excuse me, in their Medicare space. So take this opportunity to think about, well where does my
Medicaid population align with the work I’m already
doing in the Medicare space, and the work I’m starting
in the commercial space. I think there’s, like I said,
a lot of alignment here, and you’re also gonna hear from folks in the employer community, of that’s where they’re
going as well, right? So don’t wait for year three, think about, with this
new start, where do we go from the beginning? And the fourth part of this is really on some of those critical pieces of health that have often sat outside
of our healthcare system and how do we start to bring them in? Those things that we know
by evidence, drive health, but, like I said, has often sit outside. Things that we know, food, housing, transportation, jobs, violence, how do we think about those things and integrate them into our work? And so in Medicaid we’re
doing it in a number of ways, but I actually think a
number of the investments we are making transcend
the Medicaid population, and I think, again, help
us on this value path no matter where you get
your insurance from. First in the healthy
opportunity space in Medicaid, we are going to be requiring that everyone who onboards into Medicaid, no matter what plan that they’re in, that we actually just ask them, are you running out of food
at the end of the month? Are you having difficulties with housing, security or transportation? And just capturing that
data doesn’t mean we can, we have all the resources to
solve every problem right now, but we have to start asking the question, both to know about someone’s overall risk for being unhealthy, and to
start to make those changes. So we’re excited to start
to capture some of that data and understand it in a context of their other medical issues. But the two parts I wanna
spend a little more time on, related to this, is the
investment that we’re making related to a resource platform. So you ask the question, okay,
are you running out of food at the end of the month? Well, what happens if they say yes? Scary sometimes, I’ll
tell you I was scared when my patient said it
to me in my office, right? So this is what we’re
making an investment, this is a public private partnership here that is creating a
platform called NCCARE360. It is the first statewide
coordinated network to have a data repository of
all of the community resources. So all of the food banks, and all of the domestic violence shelters, and all of the other kinds
of community resources that might exist in the community. This is a partnership with United Way, 2-1-1, and Unite Us. Many of you will know,
United Way and 2-1-1 often is that data
repository people can call up about resources in the community, so we know about where a lot of those are. But this isn’t just about
having an up-to-date directory, though I will tell you,
that is not an easy thing to just create in and of itself. But this is about the
opportunity to connect what’s happening in those
community-based organizations and what’s happening in
the healthcare system. And so, it is really about
that closed loop referrals and allowing that information to become part of what it means to take care of patients, right? So we are trying to create this utility open to all communities,
where you can imagine, at someone’s practice, right? Say they say, “I’m running out of food “at the end of the month”. You have your case
manager be able to connect into this platform, you
see here on the left, they can create a new referral, let’s say to a food bank
near that person’s home, and they can create that referral and send it to that food bank. The food bank can indicate if
and when that person shows up so we actually know, did
you get the resource? Similar to us wanting to know, did you fill your prescription? We wanna know, did you make
it to get your food resource? And then that actually becomes
part of the medical record. What an amazing opportunity to start, to connect the pieces of the puzzle here that actually drive health. I’m really excited about
the two communities that we are starting to launch this in, that’s in the Wake County Community, and in Guilford County,
Cone Health and WakeMed have been the anchor in
healthcare institutions there. They have been phenomenal partners. They have been running fast on this so we’re very close to launching, but this, so this is, again, a partnership between what’s going on in healthcare and what’s going on in the community. I think the community-based organizations have been really excited about it, ’cause they wanna be closer connected. We’re all helping the same folks, right? And so this is an exciting
opportunity for them to also understand where
are their patients, and the folks that they’re helping going, and how do they get this all connected. So I think this is a
really exciting opportunity and we continue to raise
additional philanthropic funds to support this so that we can bring this to the entire, the entire state. I think it’s an important
foundational piece, and this is not just for Medicaid. We know that 10% of the
commercial population also is running out of food
at the end of the month. We know that our Medicare population often are seniors on fixed budgets that have issues with transportation, and housing, and food, right? This is a resource for everyone
here in North Carolina. So I’m really excited about it, but it’s gonna take culture change. When’s the last time
that healthcare system and the community-based organizations all sat in the same room? Not a lot of them here
today, for example, right? Because we often go to our own conferences and talk to each other, but we really need to start making all of these connections. So I’m really excited about this. I will say, Dr. Betsey
Tilson, on my staff, she’s a chief medical
officer, state health officer, has been the leader on this, and doing some really incredible work and you’ll hear from her later today. The other piece of the work
that I’m very excited about, and this is exclusive to
the Medicaid population, are some very, very large pilots that we are going to undertake
in the Medicaid program to really build the evidence-base around these types of interventions. I think we all have the notion,
and we have seen evidence that food interventions,
and housing interventions, transportation interventions,
can help folks be well and save money. And we’ve seen it in small pieces. But we haven’t actually
seen that go to scale, and we haven’t been as
precise as we need to be about what kinds of patients, and what kinds of interventions, when you like them together,
actually are sort of the secret sauce, if you will, to actually drive towards
better health at lower cost. And so this is an opportunity
for evidence generation, it goes back to that data, evidence generation to
know, well, we talk about the classic example of
kids with severe asthma, and folks in Guilford County piloting, well, let’s rip up their carpet, put down new carpet and give
them an air filter, yes. Like we should pay for carpet instead of continuing the hamster wheel of emergency room visits. So we know, that intervention
is closely linked, right? Carpet, asthma, for severe
asthma in kids, great. What’s next, what is
the carpet intervention, if you will, for high risk pregnant moms? I’ll go back to that ’cause in Medicaid, as I mentioned, I pay for
half the births in the state. So I very much want, I
care very much about mom, her health, her pregnancy, and whether or not we’re
paying for NICU care, or whether or not she’s going home after two days in the hospital, right? So we wanna understand,
what are those things? What food intervention? Not just, what food
intervention, what specificity, matched up with a particular population is really gonna drive these forward. And the federal government
allowed us the opportunity to spend up to $650 million
of state and federal money to really test these out. That means, pay for carpet,
pay for food intervention, pay for these other kinds of information in order to really find out how do we drive towards
better health at lower cost. And the structure you see
here is how we’re doing it. We’re embedding it within managed care. We have an infrastructure
that we’re building to do care coordination,
as well as to do assessment and authorization of services. Let’s use that infrastructure,
our prepaid health plan, to have those care managers, whether it’s embedded at the plan, or embedded in the practice, and use those care managers
to do that additional work to say, okay, this high risk pregnant mom with an opioid use disorder is in need of these kind, this suite of housing and treatment options, right? And they authorized some services. And what we are envisioning, is that where these
pilots are, we will have what we’re now calling a lead pilot entity that’ll essentially build the network of human services organizations, or those community-based organizations that will actually carry out the work. So similar to how managed care plans build the network of doctors in hospitals, we would have these lead pilot entities that build a network of food banks, and transportation providers, or home, folks that do home repair, if
it’s ripping up carpet, right? So they create that
network so you have someone who’s authorizing the services, you have folks that are
building that network, and you make the link together. And you can imagine that
this is really important for us to get also the data piece underlying this right. And so we have a lot of
work to do to get there. We have a lot of
operational and policy work. I will also say that, for
example, we must, in policy work, establish the first ever fee schedule. How much do we pay for carpet? How much are we gonna pay for a particular food intervention? So we have a lot of work to do. So stay tuned in the next couple of weeks. We’re gonna be putting out a policy paper that outlines a lot more of the details, but then also asks you all for feedback on how do we build this? ‘Cause this is new, and
we wanna build it well, and right, and so we can
collect the right evidence but also get the pricing right here, so we have to establish a fee schedule, we wanna understand how folks do pricing, and then we also need to think about the underlying technology needs. And this is where you
can see how NCCARE360, and this pilot can fit together. ‘Cause as we do all of these referrals we need that platform to
connect all the dots here. Do those referrals, those closed loop, and bring the data back so that we can actually generate the
evidence that we need. So, very exciting, lot of work. I can’t leave a room of
very important people who think about healthcare without mentioning an elephant in the room about North Carolina. Which means that we
have been lagging behind where many other states have gone, which is getting folks insurance coverage. And I’m not gonna dwell here, but I do want to mention
that it is an important year for us to focus on getting folks
access to health insurance. It’s time, it’s time, it’s time. So, thank you. (chuckles)
(audience applauding) So just at the very highest level, when we think of all of our own insurance, and we think about healthcare
costs, and I think most of us are thinking about that
intellectually every single day, like where, how are we gonna
drive down costs, right? If you just look at the data that shows the fact that we
have more uninsured folks here in North Carolina,
our premiums are higher. All of our premiums are higher because our uninsured rate is higher. Let me say that another way. Where we have lower uninsured rate, where folks have expanded Medicaid, their insurance premiums
on the individual market are 7% lower, right? We need to get more folks
in the tent in order to help keep the downward pressure
on costs for everyone. So we know that Medicaid expansion can help us get access to
care for 500,000 folks, half a million folks
here in North Carolina, it’s about $4 billion in federal funding that we have been foregoing
the last number of years. And the reason why it’s time now is, look, spent a number of years trying to get the program under budget, which it has been for five years, to get it transitioned to managed care, which we are doing, and to get
it transitioned to a system that when you bring in more folks, is going to be focused on value. So it’s time now to do it. We know that the way Medicaid
expansion population works, 90% paid by the federal government, 10% by states, we’re working on a proposal where hospitals and others
can pay for that expansion, so no state tax dollars will be needed. It’s time, and if we talk
about the opioid crisis that’s been plaquing North Carolina, I’ll tell you, folks ask me all the time, “How we doin’, how we doin’
on the opioid crisis?” And I say, “we’re doing okay”. I’m very proud of the
work we’re able to do with one hand tied behind my back. I think we’ve done okay. I think we’ve brought in
every bit of grant dollars we possibly could, we’ve pushed those out, I think folks are, want 50% as reduced, their number of opioid
deaths by, reduction. It’s an important, us
to do that kind of work, to drive towards value. Beyond data, there’s just a
lot of other business processes and operational execution
that’s gonna need to change as a part of this change. It was coming anyway, as
we moved to managed care. It gives us the opportunity
to say, well, okay, we were changing anyway, how do we really get it right this time,
and it’s gonna take a ton of change management work. For my own department, right? I look inward first, it’s like how do we be better partners with you,
as you do this hard work? What are the things that we
can be supporting folks on? For one example, we’re gonna be putting out a press release today. My team applied for grant dollars to help some of the work related to the behavioral health,
physical health integration. That’s the kinda stuff
where we, at the department, need to think differently. First, to seek out those opportunities and then use them to help drive some of this change management
forward more quickly. And then lastly, the culture change. What was it, culture
eats policy for lunch, or whatever, right. If we don’t talk about the culture piece, this is hard, it’s hard, and I don’t have all the answers on how do you do this right, because, like I said,
we’re somewhat going first as a state here. But I think that I continue
to hear the alignment, that folks are focused on
that North Star of health. I think that if we focus on it, that we surface the
issues related to culture and try to manage and mitigate
through them one by one, that we’re gonna be successful here, but it won’t be easy. So, thank you for the opportunity to kick off the morning,
thank you for being here, and thank you for all of the hard work that I know is ahead
as we do this together. (audience applauding) – Mandy, thank you very much. Now we do have time for a few
questions with the Secretary before she has to get on
to some of those additional meetings and announcements. There are microphones on
either side of the room. Please head up there if
you do have a question, and maybe I could kick it off. This is a big agenda that you’ve laid out, and that you’re doing a lot of work to collaborate with every
sector of the state to address. As you think about all these dimensions, are there any key metrics, or signposts that you’re tracking along the way? What are the best signs that
you’re, say making progress on the needed culture change. – Great, well, I guess the first metric is do I get to keep my job? (audience laughs) But I love my job, I want to keep my job. No, but in seriousness, first, there were some gating questions that we sort of had to get through, it was like will the federal
government partner with us? Are we able to partner
with the general assembly and help them understand? And they’ve been, we’ve
had very collaborative, good discussions with them. Now I think we are at some of, like now, operational execution places, right? Are we able to meet sort
of the gating things there? But then we get into the question of real outcome metrics, right? Which is what we’re all
hopefully focused on. And I’ll say, we are not
as good as we need to be in terms of really measuring
the outcomes we want, right? If we’re gonna walk the talk on health, we’ve gotta measure health
in a more substantive way. So clearly we’re gonna
be collecting metrics around total cost of care. It’s easy, a little bit
more, to follow the money, but we have to get better at following the health metrics. And particularly in the Medicaid space, I don’t think we do as well. There’s not as many outcome measures particularly related to
kids, which is our first wave of really a lot of the
folks going into care. But we’re getting better. And so I think it’ll be
a collaborative thing. So it’s a combination of outcome measures in the health space,
the total cost of care, and I should mention that we very much wanna collect data on how individuals, and families, and
patients are experiencing their health care. And so I’m very big on the
patient reported measures, on how their health is going so that we really get a
good sense from them, right? This is always in service of our patients, on how we are headed. – Great, so, please go ahead, and if you could let us know who you are when you ask your question, thank you.
– Sure. Good morning Secretary Cohen. My name is Jacqueline Nikpour. I am a nurse, and I’m a PhD student at the Duke School of Nursing, and I’m a health policy researcher. Sorry, I’m a little
short, so the microphone needs to come down.
– That’s okay, me too. – [Jacqueline] And I first wanna thank you for sharing with us this morning. And as a nurse who is trained to recognize and address the
social determinants of health, it’s really exciting to
see this NCCARE360 program come to life. But my question for you is
regarding the opioid crisis. And you mention Medicaid
expansion as a tool to kind of address this in North Carolina. Currently my research is focusing on improving access to
effective pain management, specifically in the veteran population, and there’s a lot of research out there that talks about the value and the use of nonpharmacologic
approaches to pain management. Physical therapy,
acupuncture, chiropractor, yoga, all of that. And currently, Medicaid
doesn’t pay for these services, so I’m wondering if there’s any effort or push to kind of transform that care, given that we know the value of these and the impact of this epidemic? – Well first, thank you for the question, and for focusing on
such an important topic. I think you’re absolutely right. It’s not just about treatment when folks are already addicted, it’s the prevention piece of this as well. And so are we expanding the amount of other pain modality treatments that we can offer? And there are some pieces where we can control
that right at Medicaid, it is very much a partnership with our general assembly to make sure that we can get some
additional flexibility, but those are definitely places that we are looking at. I believe already, and
I’m looking at my team, that we are moving down the path around changes related to physical therapy and acupuncture and others, but it does take a bit of time for us to define sort of
those policy parameters and things like that, but we definitely wanna move
in that direction, thank you. – [Jacqueline] I appreciate
it, thank you so much. – [Charlene] Hi, Secretary
Cohen, Charlene Wong from the Duke-Margolis
Center for Health Policy. As you know, I’m a
pediatrician, health service, health policy researcher. My question is, thinking about
generating culture change among the people that
all this matters to most, which is the patients and their families, I’m just wondering if you
can share any strategies around how we’re thinking about both in the public and private sector, generating that sort of culture change, ’cause it’s, even challenging us to do that within our provider entities, but think about how we
really reach out to the folks that we’re really trying to help. – It’s a fantastic question, and I don’t think anyone’s
really gotten it right yet. And, I mean the first fundamental thing is having folks at the table. But what, it’s easy to say hard to do, because you have to also
help folks be at the table in a way where they can
know how to advocate amongst folks who, like
many of us in this room, have spent decades thinking about, and they have lived experience, and how do you translate
that lived experience into the speak of like what
we’re all doing, right? And so there are a
number of organizations, the National Partnership
for Women and Families, in particular, that actually does training for advocates to help
them be great advocates, and I think that is so, so beneficial. And so we’re looking to think about, one, making sure that we always
have advisory committees, having folks at the table. But then, also helping
folks be great advocates when they get to that table, I think, is also important. I’ll say when we did our all hands meeting for our Medicaid Transformation work, so we brought 1,000 people into one room to talk about all the work, that’s just my team, the
first speaker we had was a mom who was on Medicaid, to talk to us about what’s it like
to live with Medicaid. And we need to continually go back to that as we’re designing all
of this, to go forward. – [Don] Good morning
and thank you for your, I’m Don Bradley, I’m with
the Duke-Margolis Center for Health Policy. I’m also the Executive Director for a project called
The Practical Playbook which integrates public
health and primary care, and first wanna thank
you for your leadership in this area. I think one of the, looking
at the systems part of this, one of the question is, is the
philanthropic community-based organizations in the state ready? Do they have the capacity
to handle everything that NCCARE360 will throw at ’em? And how are you gonna,
how do we deal with that. – It’s a fantastic question. And NCCARE360, if you look at actually how we’re thinking about
the budget and the work, it’s less about the technology and it’s all about community capacity. So what I would say is they
don’t have the capacity yet, but I think folks are really excited and can see the future and the potential, but it’s a lot of work. Culture work, IT, all of that. Business process work to get there, and a lot of it, this is
about thoughtful roll out of that work, and really
helping folks understand why are we doing this,
and how is it gonna work, but then taking the time to actually do that infrastructure build. It’s one of the reasons why the pilots that I also mention are not
gonna launch this next year. We know that there is a
capacity building period of time that we’re going to need for any of those, a lead pilot entity to build a network and build a network that
can have that capacity. It’s gonna take time, and we
need to do that in partnership. I’ve been really hardened
by the number of folks in the philanthropic
community that also recognize that need for that
infrastructure investment, and are working with us to help in getting folks down that path. And we have a number of
partners from around the country who have tried to do this in smaller scale that we’re working with to
try to glean best practices. But it’s definitely top of mind. – Great, thank you.
– Thank you. – [Shelby] Hi, I really enjoyed
your talk, I’m Shelby Reed. I’m at the Department of
Population Health Sciences and Margolis Center for Health Policy. And I work in the measurement space. I’m really happy to hear they’re thinking about how to measure health from patients, but also thinking more broadly
to measure their well-being, beyond their health outcomes. So that’s great. And I also wondered
whether there are thoughts about how to continue
to collect those data, even after people move out of Medicaid, because that might be where
the biggest successes are. And from a research perspective, I sort of worried that
if we lose those people, we lose their data, and
we can’t really capture the benefits of these programs that you’re putting in place. So just wondered if there’s any thought about how to collect
those data longitudinally. – It’s a great question, and I know there’s
gonna be an entire panel on talking about data and IT, and I love thinking to that place ’cause I feel like I’m
thinking about data, like just right in front of my face, so it was a really good point that we need to think beyond, and how do we interconnect here. And I know you’re gonna have folks from the Health Information Exchange here, and what role they can play over time, I think a really good point. – And, Mandy, one final question. I know you have to move on to
your next set of activities. Among the many announcements and steps that you’ve taken recently included the decisions about the award of the Medicaid Managed Care Plans. You said earlier it’s the first time the state’s moving into that space, it’s doing it with the
benefit of some experience that other states have had, with an emphasis on
changing payment systems and working with the health plans to engage the providers, the community, all the goals that you talked about. But not everybody won. Some managed care plans didn’t, some provider systems that didn’t. Any thoughts as you wrap up this session about how that process went, where you see it going from here, and how it fits into the
overall agenda you talked about? – Sure.
(audience laughs) So, look, any time there’s a process where you unfortunately have to have folks who come out with awards,
and those that don’t, it’s a challenging process. I think our evaluation committee did the best job they could to take what was written on the paper and score those things. And we sort of moved forward. I know that folks had hoped
that more provider-led entities would be part of the program. And I would say, also, before
I get too far down the path, that in any procurement this big, right? It’s $6 billion a year,
for three to five years, we recognize that folks
will want to revisit that and exercise their full rights on protests and we totally understand
that and expect that. But what I would say is
that now that we have, we know who the players are,
and we have that certainty, it’s exciting to just begin the work ’cause there is so much of it. And I think that there are opportunities, like I said, over the course of this year to think about starting
the process of contracting, even before the start of managed care, as you think about contracting, how do you think about that in alignment with all of the other
things that are going on across their other books of business? And I will say, as one of,
I know one of the plans not included were our hospital plans, the hospitals that came together for a managed care contract. And, because I think that
was a unique pairing, I don’t think I had seen that
anywhere else in the country where those number of
hospital institutions came together in partnership. And what I would just say is
that is very unique and special and just because maybe things didn’t work through that process, I think
there may be opportunities to think about how do
you use that partnership and that structure to think
into the value-based work and the contracting
structure in the future. So I think we have a lot of work to do. Everyone’s gonna be busy doing that work, and we will continue
to be open to feedback and I’m trying to be as
transparent as humanly possible on how we’re thinking about things, and I just look forward
to everyone’s partnership as we move forward. – Secretary Cohen, this is not easy. It takes a lot of tough decisions, but thank you for your leadership on trying to move
everybody forward together. (audience applauding) All right, while I ask the next panel, our first panel to come on up, this is on Pressure for Change, Perspectives from Employers,
Consumers, and Providers. Just a couple of things. One logistical comment,
as you’ve probably seen from the agenda, we have a packed agenda, a lot of speakers with
some diverse perspectives and a lot to bring,
along with your comments, to the discussion today. What we don’t have a lot
of is breaks scheduled. That’s okay, I think. If you need to stretch
your legs, step outside, please go ahead, that’s okay. I don’t think it’ll be too disruptive. We really appreciate
all of you being here, and we wanna give you the most out of the time we have together. With that, I’d like to
introduce Gary Salamido, the Acting President of the North Carolina Chamber of Commerce,
who’s going to moderate this first panel. Gary, thank you. – Good morning everyone. – [Man] Good morning. – It’s good to be here this morning with such distinguished folks. Again, I’d like to thank Secretary Cohen for all the hard work that she’s doing. She’s tackling one of the toughest issues that is facing business,
and she’s doing it for our state government, for our state. So thank you to Dr. Cohen. Thank you to the Margolis Center for pulling us folks together today in a part of this drive,
this transformation to value-based care. It is getting people from
different perspectives in the same room, talking to each other, and building the bases
for the collaboration that is so necessary for the hard work that we have ahead. Please know that the employer community, our North Carolina Chamber members are committed to the
hard work that’s ahead. It’s in the best interest of our people, of our citizens, it’s in the best interest of our employers, and the best interest of the long-term
competitiveness of our states. So I’m gonna give you a
little bit of background on me and why the chamber is sitting here, and then I’m gonna introduce our panelists pretty quickly and get to them. They’re the ones that are gonna give you the most insight today as to where we are, what the pressure is, and why now, why this, and why now? So, my name’s Gary Salamido. I’ve been in North Carolina since 1992. I’m a health professional by education, who’s spent his life in
the association world, had 19 years at Glaxo, Glaxo Wellcome SmithKline, in the policy and the advocacy arena. So healthcare has been in my blood until about eight years ago, and it remained in my blood through the North Carolina chamber, because as we looked to
what the key challenges and the key issues for
the business community are in order for North Carolina to maintain it’s competitiveness, two issues consistently rise to the top when we poll our members, when
we poll our CEOs every year. And it’s healthcare, healthcare costs, healthcare outcomes, and
education and talent supply. Both of those are one and two each year. And actually you could
argue that they’re one. They’re inextricably linked together. The two issues that are
remaining for North Carolina, there are other ones, but
the big issues remaining for North Carolina, for us to maintain our competitive advantage regionally, nationally, and globally,
are those two issues. And healthcare is right
at the top of the list. North Carolina ranks at
the top of a lot of lists. Healthcare value’s not one of ’em. We’re 33rd in the nation. We have some of the most
challenging and worst outcomes and we pay some of the
highest prices for those. That’s not a place that’s sustainable. And our membership said,
okay, we all know that, but what are we gonna do about it? When are the employer community gonna get re-engaged in this process? The non-healthcare employer community. First thing is our foundation said, we need a common language. What was not happening in our board room and with our members is, we have a very diverse group of members across a whole bunch of industry sectors. And we were speaking past each other. The healthcare and the
non-healthcare members of our organization all
wanted the same thing but we didn’t have a common language on how to get there. So the first step was, what is that? We did some research and we released what we call a roadmap one, roadmap to value-driven healthcare, which began that process of saying, if we’re gonna do this, and
we’re gonna collaborate, and we’re gonna get to be a top 10 state for healthcare value, we gotta be talking about the same thing. So we were able to find a framework that whether you’re a
manufacturer of T-shirts, which we have, or you’re
in the quarry business, or you’re a health system, or you’re a pharmaceutical manufacturer, or a lab company, everybody
understands supply chains and strategic supply
chain management with it. So when you begin to
look at common language, all of a sudden, those
folks, those executives were hearing the same thing, and they were beginning
that process of saying, okay, now we can get our arms around it. So step one was common language, identifying critical success factors, and then begin to talk to our folks, okay, now that we’re here,
what are the next steps? What are the key components? What are we doing well? How do we benchmark ourselves
against other states with it? And we found out a couple of things. One, collaboration’s the key. Number two, data, it
has to be data-driven, all the things that folks
in this room know very well. You need local leadership. You need people not
only at the state level, but in the communities, you
need that kind of leadership. And you need the will to win. At the end of the day
you need the will to win. North Carolina is really
in a good place, position, and we have all of the ingredients, we have all of the talent,
we have the best technology companies, go down the list. The question is, is do we have the will? I think we do or else we
wouldn’t be in this room today. You all wouldn’t be here today with it. But the time is now, the time
to catalyze transformation is now, it’s in the best
interest of our citizens, it’s in the best interest of
employees and their families, it’s in the best interest of our state from a future and current
competitiveness position. So know that we stand
committed at the NC Chamber through our membership and
through the business community to do our part to catalyze change. And the last piece before
I introduce our members is what else we learned is
that it’s time for all of us along the healthcare supply chain to put our swords at the door, and to come into the room
and have the hard discussions with a common definition
of North Carolina winning, and North Carolina being
a top 10 state for health. So we can have those good discussions, and we’re gonna need to have ’em, and we are having them, but the time to put those swords at
the door is right now, and the time to win is in the next five, to 10, to 15 years, and
to create a sustainable, competitive advantage for our state. We’re ready to go. I’m gonna get going here and introduce our panel real quickly. They’ll give a brief
introduction to themselves which will be much more
detailed than I can provide. Really privileged to have a real talented group of folks with us here today. The far left is James Sills. He’s the President of
Mechanic and Farmers Bank. So he’s gonna give you
an employer perspective and a perspective from the
people that he works with, his customers, on what
healthcare costs mean from an employer’s perspective. And equally importantly, he’s on my board, so please be nice to him today. (audience laughs) Next to him we have Mr. Hugh Tilson. He is a Director of North Carolina AHEC, an incredibly talented healthcare policy and advocacy professional
that has been a good friend for about 20 years. Hugh and I have been in the
foxhole together before, and there is very few other people I’d rather be here with to
start this journey with today, so thank you, Hugh, for being here, and for your friendship. And then to my left,
it’s Dr. Corey Booker, President and CEO of OnPulse. Corey’s a physician, he’ll
tell you a little bit about his practice, which is inspiring, for what he does. And also he’ll talk to you a little bit about what he does for patients, a lot about what he does for
patients and their families, as they looked, and A, see
what their expectations are and get clarity of their
expectations of the system and how to navigate it. So with that, please welcome
our distinguished panel. (audience applauding) Okay, let’s jump right in. Why don’t we start, Jim, let’s
start with you on that end. I’m gonna assume that, and I know, that we’re gonna be
successful transforming to a value-based system. In your mind, from an
employer’s perspective, in five years, in 10 years,
what’s that look like for you and your company? What’s it look like for the patients that are employed by you,
and when we get there what’s the one thing you’ll see? – Gary, thank you for that introduction. It’s great to be here this morning. I’m really pleased to be up here with such a distinguished panel. I really wanna congratulate
Duke-Margolis Center for hosting this event this morning. I’m local to Durham. I’m the President and CEO of
Mechanics and Farmers Bank. We’re a community bank, based here. We’ve been in business for 112 years. To answer your question, for our company, under a value-based system, our employees have to be better consumers of healthcare. And they have to be, they
really have to embrace the value-based concept. And I think there’s opportunity for our staff to utilize
information better, they have to change their behavior, and I think over time we’ll get there. I just think it’s gonna
be slower than you think. And everybody wants to do it now. But it’s just gonna take time to actually get to that solution. – Great, thank you Gary. I appreciate the opportunity to be here, and appreciate working with you. In addition to commending Margolis, I really wanna commend
you for the leadership you’ve provided in this space. Not many chambers that I know
of are taking on healthcare the way you are. It takes leadership and courage, and so please keep it up. So I’m talking about the
perspective of rural physicians, and rural physicians
have two perspectives, one is as a business entity, the other is as a caregiver. So what does the future look
like from both of those? The main entity is sustainability. Given the payer makes the
challenges of rural communities, trying to figure out how they can continue to do what they do, which is provide value to their community already, rural providers are just different. They’re integral parts of their community, they know their community,
they do whatever it takes to make it work. The system doesn’t support that. And so, five years from
now, in order for them to be sustainable, we need alignment. What Secretary talked
about, all these plans coming after them or at
them with different ideas of what all this looks
like, gotta figure out a way to help them process that so they can do what they wanna do, which
is take care of patients. Gotta create an ecosystem where they can actually be supportive. My colleague, Sam Cykert,
talks about the ideal rural practice and the supports necessary to accomplish that. So how do you recruit the right people to those practices? How do you build a team
of care around that so it’s not just the physician, it’s the community health worker, it’s the nurses, it’s the pharmacist, the people that translate
the data into action. That whole team is what it’s gonna take to make that alignment actually occur. And then the Secretary
talked about coverage. In order to make all that happen, patients have to have robust coverage so that the services that these
small businesses providers can provide are reimbursed
fairly inadequately and consistently, most
importantly in a way that enables and drives their work, not becomes a barrier to it. – Thank you Gary. So for me, when I, when we come here and you sit across the table from someone, when I’m getting called in to an employer, my team is a high-risk
team, people call us when there’s problems. And I’m a practicing physician. I take care of complicated pregnancies. I’m also known as a perinatologist and maternal fetal medicine doctor. But in my work on OnPulse, typically when we come
in, everyone, I sit down, and we’re all looking at each other, and I say, all right guys, what do you want, why are we here? ‘Cause we know somebody wants something, and they say, “Ultimately Corey”, and this is the employer speaking, “We wanna be better
stewards of our dollar, “and we wanna make sure our people “are taken care of, that simple.” But, they have these claims, this rate that keeps going up every year and they’re not sure how
to balance those things. And at first I really didn’t, I didn’t understand why
they didn’t understand, and then I kinda reflected. I’m gonna tell you three
stores that, to me, kinda brings this
together in my experience. The first story is me as a provider, and taking care of families that are in, they get news that their baby
might have a heart defect, or they get news that they might have to have to be delivered early because of a medical
condition a mother has. That expectation around
what their pregnancy and their future looks like changes, and despite all my efforts, they will walk out of my
office really distorted, and I feel like I did a great job. And I’m kinda frustrated, like man, why’d they look like that. This is great, it’s textbook. And so on a provider side, I’m frustrated. But then the other side
is, I have five kids and every summer we’re at the pool. And so I’m hanging out at
the pool, reading a book, and sitting on the side, and inevitably, like every three visits,
someone will come up to me that I don’t know, but
I kinda see the look and I know what they’re gonna ask me. And they said, “Are you Dr. Booker? “I was just talking to your wife, Cathy, “do you mind if I talk to
you, you’re a doctor, right?” And I said, “Yes”. “Well, I’ve got this problem.” And they do this, right? (audience laughs) “I know you’re a baby doctor, “but I know you went to medical school, “can you look at this?” And I’m thinking, I used
to get frustrated by that. I said, “You know, I’m at
the pool, I’m not at work, “I’m hanging out.” And I lacked empathy at the moment. And then all of a sudden
I put the two together, what I was experiencing,
and with my patients, when they were leaving and not sure about what I was saying, and
then what I was experiencing as a doctor in the community, just being a normal human being, who’s someone who’s employed, and they’re lost to the system. And they just wanna talk to someone that has no skin in the
game, that should know what they’re talking about,
and they could probably trust what they’re saying. So those two stories have really moved me into creating OnPulse. And OnPulse is, we call
it a personal healthcare management service that’s
there to guide people through the health system
and give you confidence in navigating the health system. But the third story was
probably most impactful. When I started the company, we thought it was a technology company. It was right when EMRs were coming out, we said look, this is the problem, people and doctors just need
to talk to each other better and it’ll be all good. And we had a family that
had a rare diagnosis of cancer, lymphoma, moved
from Florida up to New York. And I was speaking with her, and she, we had cared for her for some time and suddenly she called the office and said, “Can I speak to Corey”. And I said, and the team said, “Yeah, “here, here you go.” So she picks up the phone and she said, “Hey, Corey, I know you know me.” I said hello, and she
says, first thing she says, she says, “Hey, Corey, I have cancer”. And I said, “Yeah, I know, I’m sorry. “What can I do?” And she says, “You haven’t heard me. She says, “I have cancer.” And I said, “Yeah, I just,
what can I do for you?” And she said, “Listen, when I get home, “and I’m nauseated and
vomiting after chemotherapy, “and I have bills piling
up in the corner.” And they’re staying in a
hospitality home for 18 months. She says, “I don’t have time
to look at your technology.” She says, “Look, why don’t
I make a deal with you. “I’ll pay you five times
what I’m paying you, “and you give me somebody.” And I was sitting there, and I said, “Why would you do that?” And then she looks, she
says, she was quiet, and then she says, “I’m sorry, but Corey, “you don’t know what the
hell you do, do you?” And I said, “What?” And she says, “You know, the
reason why I work with you all “is because you help me
through the health system, “you guide me, and I need your help. “I don’t have time to look
at the technology no more, “I need you to guide
me through the system. “I need someone who knows
this better than me. “I don’t understand all this stuff.” And so that was our
first time really moving into more of a service. And with that case in particular, we assigned a billing and coding person to audit her claims. And we saved her and
her employer $150,000, just by realizing they were being billed both in-network and out-of-network fees. And, you know, those three stories, to me, really tell the story of
what we’re dealing with, and why we’re all here,
and what’s happening from the employer side. When they say, I wanna be a steward, what they’re saying is,
I just wanna make sure I’m paying for what I’m paying for, and my people are getting cared for. And so, that’s my perspective here today. And I think in terms of helping folks get through the system, I think it’s about giving people a framework in
which to approach the system, giving them a plan and
then helping them measure how they’re executing
on those three things. – Thank you, all three of you. One of the learnings that we had, too, was that, what’s the
definition of a payer? And what came through was
that everybody in this room is the payer. Whether you’re a person paying
your own health insurance, whether you’re an employer, an employee, and someone paying your local
state and federal taxes, all healthcare is paid for by people, in one way, shape, or form. So we have employers,
and we have patients. Let’s talk a little bit now about, from each of your perspectives, a couple of ways that
you would like to see employers and patients engaged, and then if we’re successfully
trending and tracking in the right direction,
what is, in five years, what are we seeing that
we’re not seeing now? From the patients, and from the employers, and that group of folks
that has to re-engage in a meaningful way to make this happen. Hugh, let’s start with you,
from the rural perspective, from what your work at AHEC and your past, what are a couple things
that need to happen, and if we’re doing it
right, what’s it look like? – Well, I think, one of the other things that we need to figure
out how to do better is figure out what we’re buying. Because all the things
that you’re talking about are within the existing system, how do we pay for what we do? But there are increasing data available that show that what we’re buying isn’t necessarily what
we ought to be buying, and what businesses are paying for, not necessarily correctly,
but even incorrectly, isn’t necessarily the
things that produce health. So as we look down the
road at how businesses and employees can come together and figure out kinda what it is that they’re trying to do, in an ideal world, this
becomes an investment not an expense, right. So in an ideal world, the
things that business is doing for their employees is
investing in their health because it actually keeps them healthy, it keeps them at the workplace, keeps their children
healthy so they can continue to focus on their work. In order to do that, you need data. You need transparency,
you need accountability. And you need the right people trained to do the right things at the right time. I would posit not all
of those exist today. So five years from now, in an ideal world, you have the alignment of the people who pay for the care, the
people who get the care, and the people who deliver the care, all transparently working
towards the same outcomes which is health, not
just providing more care to sick people. – [Gary] Jim. – Yeah, thanks Gary. In five years, I really
think it’s really important that as the Secretary
mentioned earlier today, we have to change the culture. I’m an employer. A lot of times, employers,
they just throw their hands up because they say healthcare costs just continue to increase year over year. Our organization is actually
a part of an association of banks, where we have, we’re a part of 2,600 Lives, as a part
of that group program, but it’s really important
that all of those employees in that program are actually
as healthy as possible because that will help drive down cost. And as the leader of a business, I think it’s really incumbent on me to change the culture,
to ask tough questions of our CFO and our HR director, how can we lower the cost? What programs can our, what programs can our employees take advantage of to help
drown the cost of health care. And if every bank in our
association does that, eventually health care
will actually go down, that’s our view. Secondarily, I think it’s technology. It’s amazing what the various apps that you have on your cell phone and how you can count calories now. You know if a Big Mac and fries, you know what the value of that is on a Weight Watchers point system. You can figure that out very quickly. So I think eventually
you’ll see more and more in five years, where our associates, or our employees will be
able to do cost comparison of an MRI, other health care needs, and actually go to the cheapest provider who’s providing kind of a similar service. So I think that’s where it needs to be. We have to change the culture. I was really encouraged by the comments that the Secretary made, and we have to leverage technology. – In some ways, I think this
is a tough question, Gary. I think it’s a tough question because there’s a couple
of underlying assumptions in this one statement,
and one of the assumptions is do patients actually wanna
be in the health system? The answer’s no, they wanna be at work and they wanna have fun and
be with their families, right? They don’t actually want to be
in the health system at all. So, and then, so there’s that. So by the time you actually
step into the health system, first of all you’ve
been trying to avoid it, so by the time you actually get into it, it’s your first time hearing whatever somebody’s telling you. And if it’s your first time
being told you have diabetes, you don’t know the difference between do I need to go to a family
doctor for this management or do I need to go to a endocrinologist for this management? And your employer doesn’t know what to tell you either, right? And so, I just think that, to get everyone along on the same page, my team and I, we’ve gotten to a place
where we just think that we need to give
everybody a simple framework, and we give our employees
and our families a framework, and there’s a five part framework of which we ask them to step through, and these questions will allow them to know whether they’re
potentially on the road to getting value. And so, in order to get, and this is the along the lines of what Jim said, and also Hugh, which is how do you equip people? And I think it is giving
them a simple framework in which they can
navigate the health system and have a path that says,
I’m on the road to value. – Gary, can I just chime in? I think, one of the
interesting observations is you say the health system, but that’s when they get sick. And so one of the questions that we are kinda skirting around, which is how do we help
people to be healthy? ‘Cause people don’t wanna be sick, which is I think what you’re saying, but the system isn’t designed
to help keep them healthy, it’s designed to not treat
them very efficiently when they do get sick. – Now we.
– Go ahead. – Yeah, it’s a great point, Hugh. And one of my pet peeves is there’s, not to disparage any provider, and I’m not gonna give
you the specific provider that we utilize. But they have a $100
incentive if an employee does X, Y, or Z. And you just mentioned
that you want our employees to be healthier. I actually think that incentive
should be a lot higher, because we have such a small percentage of our work force that
actually participates in those various specific plans to receive that incentive
of $100 gift card, and I think if we’re
really trying to encourage healthy, health and wellness, and healthier employees,
so they don’t really focus on getting sick and leveraging the system. There has to be greater
incentives to be healthier. And those incentives need
to come from the providers. It’s gotta be more than $100. – And I would just piggyback
on that a little bit. If you look at an employer
that has a hundred people, this probability sits
correct across the board. 30 of those people will be
driving 95 cents of every dollar. So, you don’t, yes we do
need to tackle the 70, we absolutely do. But where all the waste in
the dollars are right now, is in those 30 people, that
if you really engage them particularly, you will
actually uncover those dollars that might go towards incentives towards the lower 70 that will help them begin to be healthier. And so, what I focus on as a team, and I talk to employers,
as a team internally, when we talk to employers, we actually talk about caring first for those people that are the drivers, and helping them navigate
the health system, and in those areas, we
actually uncover the waste that can then be, those
dollars can be redistributed back into the company at different levels. – Let’s shift just a little,
I think it’s a nice segue. One of the things that we
learned through both studies, through talking to providers, talking to non-health provider companies is thinking big is great. We’ve got great ideas,
we’ve got great plans, we’ve got some key elements to it, but you have to act small. So, let’s talk a little
bit about what’s working and key building blocks going forward. But what’s working in North Carolina? What are some of the things that we can let other folks
around the state know about and key building blocks as
we, one community at a time, begin this transformation process that will be hard, but we all
know and are committed to. So, Hugh, let’s start with you again. – So, the medical community
is trying really hard to understand actually
what and when it takes to transition to value. The current incentives
aren’t for that transition. So, we are, the medical community
is trying a lot of things. You heard the Secretary
talk about Medicare, ACOs, there are a lot of
ACOs that are up and running and they’re learning a lot. We have a robust patient
center medical home model in the state that’s been highly effective. We have an HIE that’s
getting up and running. It took a little longer
to get up and running than it might should have. But all those things are coming together to try to, to provide a platform to change the focus and to build off of those learned successes. And so the challenge is gonna be, how do you leverage those,
how do you grow them, and how do you build on those? How do you celebrate
those local successes, but just as importantly
share that learning so that others can learn from it but also don’t make the
mistakes that others did as they were getting started in those. Bottom line is, that from
the provider perspective, there’s some really good
framework and learning that’s going on. – Corey, what’s working in your world? Yeah, one of the first things
we encourage employers to do is to find value for themselves. A lot of times, when we do get
invited to speak with them, they start off pointing fingers
at the healthcare systems, the insurance companies,
and I’ll ask them, I’ll say, “Well, what do you
all feel like you can do? “What’s something that’s really important to your organization?” And that gives them to think about, what does value look like
for our organization, because we work with folks
that are in the tech company, tech business, the wealth
management business, farming, their cultures as
you can imagine are different, their work force is different. They can’t go out and
they’re not gonna ask for the same things. And their culture and how they communicate with their employees,
and what their employees are like are different. So we first asked them to
define value for themselves, and then from there, we
helped them develop a culture that every, the whole
employer organization begins to try to go
through the health system the exact same way. It’s not a ration, it’s not restricted, but can you, if you have a
culture in a organization, you can find value for your organization, then you can take that
approach as an organization. I still think it’s worth
having a lot of conversations with insurance and providers
to work things out. But in the meantime, you
can still work on yourself. So that’s what we see is working. – A quick follow-up. We’ve had some discussions, Corey, and you’ve given me, in those discussions, a couple examples that are
really illustrative of that. Give an example of someone
you’ve worked with, or a patient, anonymously of course, that you’ve worked with
where the system has worked and it’s really made a
difference to the patient and to the employer. – Yeah, so a lot of our clients, just to give you a little bit of context, we do focus initially on
the high risk individuals. We might, an employer might ask us to work on the top 5%. And a couple examples is, one,
I told you an example earlier with the family that was in New York, and working with them and helping them not only navigate the system
for cancer care in New York, but also saving them
money on the back side. A more recent example, it’s
actually one of my favorite ones because it’s, I call it a black swan. It’s that thing you didn’t
know it was expecting and it came out. And we have an employer that a worker has been in and out of the
ER for the last six months, maybe had six or seven ER visits. And what we realized, and
they had also had surgery, and the reason why they were
in and out of the hospital was because they were
told that their surgery would have a certain outcome, and they should have a certain experience. And they weren’t aware of the
complication rates that exist. They were actually normal for
this particular procedure. Well, this individual was considering leaving the practice, and we went in and spoke with him and then actually got to speak with the surgeon. And what we had discovered was, the reason why there was lack of trust and they weren’t speaking
with that provider was that provider was
actually leaving the hospital, leaving that practice completely, while this patient was still feeling that they were having complications. And so they were gonna go
to a whole new hospital, try to get a recert, a
re-do in the surgery, and once we discovered that,
we were able to work with him, actually help the family realize that actually, you’re actually
on the right path to care, this is a complication rate
that you didn’t realize was there and you need to wait another several period of time before you try to pursue
anything different. And ultimately, this saved that employer another $50,000, just
by helping him realize, you’re actually in a good place, we’re sorry this provider’s leaving, you didn’t realize that. But let’s create a new team where you are. So that’s an example of
some work that we would do, that would, I think, that
benefits our employers. And they’re black swans,
because oftentimes no one really knows
what’s actually going on, and so they’re kind of discoverable cases that we enjoy. – Sounds good. Jim, in your bank and with your employees and the folks you interact with. What are some things that you’ve seen that are working for you, and how do we replicate some of those if you can, if you can. – Yeah, I’m just gonna
really give a global answer. I think one of the things that is working is me participating in this event today. I also think the chamber
bringing this issue up to our membership about health care and the cost of health care,
and the different programs that are out there that
can help lower health care. Generally speaking as a
president of an organization, we only talk about health
care maybe once a year. We’ll have our provider
come in and actually explain to us the provisions of the plan, and some of the increases. But I think it’s incumbent on all of us to continue the dialogue of
this type of conversation with employers and providers
and medical professionals. So I think that’s working. We’ve just gotta continue
to do more of it. And it’s a great first step, but we just gotta do more of it. – One more question, and
then we’ll open it up for questions from the audience. The employer community
disengaged for a number of years in a lot of ways in this. They worked with professionals, they worked with organizations, and they said, here’s where I am, here’s what I’m willing
to pay, negotiate it, and then they kinda stepped away. They’re beginning to come back. Cost is an issue for them, and they’re seeing that their folks aren’t necessarily as healthy
as they want ’em to be. Equally, what we’re seeing more of is it’s not the employee themselves that is the challenge, it’s
the relative of the employee and the employee’s taking
care of that relative a little bit more. So employers have disengaged
to a significant degree and we need to catalyze that back. A good example is our
health care conference is doing really well, but it’s 95% health
profession organizations, and only 5% non-health profession organizations and companies. So, we could use your all’s help. What are some of the things
that you think we can do to mobilize employers, to re-excite them? We’re beginning the process
now, participating here. But how do we get, just
in a simple way to, how do we get more people that are not in the health care space to engage with the health
care provider community in events like this? (audience laughs) – You know, I’ll take that one. (audience laughs) Since I’m the, I guess
I’m the 5% minority today. (audience laughs) I’ll just tell you a quick story. For the past 17 years,
our healthcare costs have averaged an increase of 6.8%, for the past 17 years. And that’s just not sustainable. And so, my job, and my role
is to ask questions why, and what can we do better? And I really think it’s incumbent on me to be that cheerleader
for our organization to be healthier and smarter. And so, please invite me back
to these types of events. We need to know, or understand, kinda, some of your challenges,
but at the same time, I think you need to understand
some of the challenges that we’re facing. That increase continuing to go up, it’s just not sustainable. So we have to work together to figure out how can we drive the cost down, or at least reduce that annual increase to a more realistic number
of two or 3% a year. – [Mark] You, Corey? – Well, I think the problem is, it’s hard. So business leaders are busy. And coming together to
talk about a problem, but we all know what the problem is, may make us feel better,
but at the end of the day, if we walk out of there
and scratch our head and say, what did we accomplish, and how are we actually gonna
move the needle on this, people stop doing that after a while. I know I don’t go to meetings where I feel like, okay,
what did I accomplish? So I think one of the challenges, how do we find consensus
about pathways forward? And how do we continue to
have meetings like this where at the end of the meeting, we walk away saying, here,
one, two, or three things that we can take away, that
we know make a difference, and that we’re either
gonna try individually or gonna try collectively. The challenge with healthcare is that everybody else owns it, right? So if you talk to the insurance companies, it’s those darn providers. If you talk to the providers, it’s those darn insurance companies. It’s the employees that aren’t
taking care of themselves. The truth is nobody does own it. But until we kind of can figure
out a way to move forward and collectively try
things, I think frustration will continue to be the
leading response to that. I would just observe
that we’ve been having these conversations as a country since Medicare, Medicaid. So there is no easy answer,
but I commend this today, so thank you for pulling this together and continue dialogue. We just need to translate
that into action. – I know, no offense, Gary, but I know many of my clients would not come here. And the main reason why they wouldn’t come is because they’re better
at making their widgets and delivering their services, and carrying their people than they are in trying to figure out health care. So I think that to get them here, you would have to first come to them, and then have them see
that there’s a place here and give them some tools of which they could be really enter
into the conversation, have the confidence to
enter into the conversation. It’s intimidating to be an employer that sit up here and then
try to talk to you all, when you eat and breathe this every day. So, that’s what I think. – Okay, it looks like we got
about 20 minutes or so left and be happy to open it up to questions, comments from the audience for our panel. – [Man] Good morning and thank you for all participating today. This has been very enlightening. One of the questions I
have is it seems like the employee-based groups
are very interested in wellness incentives,
in wellness programs, in order to shift the cost curve, while the most recent academic evidence has suggested that these
programs do very little besides split the risk pool
and/or screen for health without actually changing
aggregate behaviors. Do you have a response to that, and the other question I have is the elephant in the room has been cost. There’s been very little
mention of actual unit cost instead of services received. So do you have any thoughts on that? – Who wants to try it on? – I don’t think I fully
got the second question, but the first question was
that the wellness programs, I guess you would say,
have been underproducing in some level for employers. – [Man] Significantly so, yes. – And then your question to that is, do we agree or is that,
to follow up on that, or what are our thoughts on it? – [Man] What are some of your thoughts on the academic research suggesting that they’re not that effective, while it seems like the
employees are all-in on this space. – Yeah, I’ll take that one. I’m a health, I’m a member of the North Carolina
Bankers Association’s Health Benefit Trust,
I’m one of the trustees. And we have 2,600 lives that we ensure. And believe it or not,
out the 2,600 lives, we only have about 150 people that take advantage of
that incentive plan, out of 2,600 lives. So I think it’s important that the CEOs of the North Carolina Bankers Association are aware of that statistic,
and they encourage their employees to take
advantage of those incentives, but the reason why that
percentage is so low, or that number is so low, because $100 really doesn’t mean a lot
to the average employee. So I think if those programs
increased the incentive, and I’m just gonna throw
a number out there, to $1,000, I think you would
get higher participation. And our bank, and a
lot of the other banks, and a lot of other
organizations around this state would encourage that participation also. ‘Cause you will get a better, healthier, more productive employee, if he’s taking, he or she is taking advantage of those kinds of programs. – [Man] Thank you. – Can I just add one other quick thing? And that is that I think
people wanna be healthy, and so, whether the existing
programs produce that, the question is, how do we
continue to learn from that, to take advantage of this basic notion that people do wanna be healthy, and make it as easy as possible
for them to do those things and then translate those into outcomes as we continue to learn more. But systems can’t make people healthy, only people can make people healthy. Systems can help people be healthy, and we need to make sure
that’s what’s happening, but in general, the idea of being healthy requires immediate short-term sacrifice. You eat less, you exercise more, you do those things that
provide you immediate, you don’t do those things that provide you immediate gratification ’cause there’s longer term gains, and so how do we create the systems that help people do what they want to do, which is be healthy. – [Heather] Hi, my name is Heather Frank. I am a third year medical student doing health policy research
here at the Margolis Center for Health Policy. I’m interested in this idea
of consumer engagement. So you mentioned the need for employees to be better consumers,
and also for providers to meet people where they are, which might be in the community. I’m wondering if you have
examples of strategies that utilize these simple frameworks of how we can do this,
especially considering, for individual patients, a lot of times these decisions are very emotional, in thinking about behavioral
economic principles, emotional decisions are really difficult to be sort of rational about, and think critically about those decisions in the moment. – Yeah, that’s a great question. Thank you for that question. Here’s something we’re discussing at the North Carolina Bankers Association. When a patient goes out
for a MRI, or a CT scan, there are, believe it or not, there are different
providers and different firms charge different amounts
for different kinds of MRIs. So why not have that consumer, or employee shop for that service, that MRI, and give him a portion
of that savings back. And so that way we could change behavior by ultimately lowering health care costs by having them have some skin in the game and actually get a rebate for going to the lower cost provider. – [Heather] And that evidence for these sort of transparency tools would suggest that maybe 10% of people are using them right now, and less people are using them multiple times. Are there ways that you think we could make those tools better, maybe? – I think it all goes
back to the smartphone. A lot of providers and healthcare systems are starting to put
their costs out online. And so I just think if
there is an incentive that would allow them to save money by going to the lowest cost option, I actually think they’ll use technology to figure that out. – [Heather] Thank you. – [Gale] Good morning, or,
yeah, it’s still morning. I’m representative Gale Adcock. I am also a family nurse practitioner, and the Chief Health Officer at SAS, one of the employers that
provides healthcare, hello Corey. And I just wanna say
I’ve had both a question I’d like the panel to respond to, but I also wanna make a statement. And that is that I think it’s a mistake and a missed opportunity
when employers equate health with their health plan,
because it really begins before the health plan. And I come from an environment
where we try to create, and we’re not unique in that,
but we are a leader in it, try to create a culture
and work environment that promotes health, that
actually creates opportunity for employees to make healthier choices. And I have five examples for you, okay? The food choices that an employer decides to provide at work, and I’m not talking about necessarily providing
free food to your employees, but the type of vending
machines, if you have them, that you have at your workplace. Is it all Nabs and full sugar drinks, and there’s no water, there’s
no other healthier choices. Opportunities for movement during the day, so do you have walking trails? Do you have even any kind
of exercise equipment? Or things that more passive than that? Employee health education at work during the lunch time or for employers who have 24/7 operations, at different times during the shifts, some schedule flexibility,
work schedule flexibility for employees so they have some
options to either exercise, meditate, or even get outdoors for some good old outdoor therapy, and access to an employee
assistance program. Because once we acknowledge that many physical health problems are driven by psychological
and social problems, you can often then save money all around. But I think it actually
begins with your work culture and I’d like to get the
response from the panel about what you think employers
are thinking about this and doing about it, thank you. – Sure, Gale, thanks for
your comments on that. Your question is what
are employers thinking about this in particular, is that, did I get that right? You know, we see, we work
with employers down to 50, up to 5,000, and so every employer across that gradient of
lives that they’re caring for are thinking differently based
on their resources, right? But I’ll tell you the
one, the number one thing that affects their ability to
do what you’re talking about is the culture in that organization. So if the culture isn’t one where there is a strong relationship between leadership and the front lines, they can’t influence
that kind of behavior. They don’t really know how
to engage their employees to influence them to begin making those, to be making those types
of behavior changes. So, what we’re seeing across the board, every company, no matter what size, who has a strong culture, if
you make that recommendation, they’ll likely, they’ll
find ways to do it. So that’s really what we’re seeing. – [Gary] You or Jim, any? – Yeah, I agree. It comes, you know the Secretary, I think she hit the nail
on the head, it’s culture. I think it’s my role to create
that healthy environment at our bank, at our institution. We have biggest loser contests, we do all kinds of things
to kinda really stress health and wellness. I’ll just share this with you, just to get a laugh in the room. We stopped serving doughnuts
about three years ago, ’cause you’re right, employers
contribute to a lot of this. They’re serving candy,
and doughnuts, and sodas, and it’s just not healthy snacks. So I think it’s a two-way street, and we have some obligation
to present healthier options to our employees when we’re
doing things with them. – So combining a couple
of these conversations, the question that I have, Gale, is do you have an ROI on those? And so, as we’re thinking about creating those cultures of health,
as business leaders, it’s not just because it’s
the right thing to do, but if we can also demonstrate
that it’s a good investment, then that might help to advance those. And so one of the things
that maybe we can do is look for those case studies that work with those ROIs and make
sure they’re widely available so that the decision
is more broadly focused and they’re just doing what’s
right for your employees. – [Keith] Hi, my name is Keith Duprey. I’m with DHIT Global,
which is Digital Health Impact and Transformation,
and we’re a social venture trying to coalesce the conversation around how digital health
tools and technologies can impact health care here in the state. First I am so proud, or not proud, being behind Gale Adcock,
what an amazing person to follow-up with on our great question, what she’s done around the idea of health with SAS is remarkable. So just, what an honor. Two, that kinda brings me to our question which has been, I’m excited
to hear more about today, is around this ideal of culture. I think that’s a really
challenging thing to think about. I love this idea of investment. Maybe Mr. Sills, this is for you, what other tools and resources are you looking at to
truly help your leadership understand what culture
change really means, and how you plan on truly implementing those cultural changes
in your organization? – Thank you for your question. We’re a small organization. I wish I had the budget of SAS, ’cause everybody would
be a whole lot healthier. (audience laughs) You know, it’s a situation
where I think it’s important that we talk this subject
more than once a year. And so when we have various events with our individual
teams, I ask the question, are you doing anything healthy, are you doing anything active? What kind of foods are
you, are you serving pizza and fried chicken? I think it’s almost coming to that now, that we have to promote
healthy lifestyles. I also think it’s real
important, as a leader, that you’re aware of what’s going on in your individual community. So I’m involved with Healthy Durham. I’m also involved with Duke
University’s Chancellor, Chancellor Washington,
he has an initiative where he’s involving the community. I think we should know who some of the health care providers are, and are they a center of excellence that’s providing low cost services, but getting excellent results. So I think it’s just a matter of, it’s not gonna happen overnight, but we need more business leaders that have that mindset. So it’s just gonna take time, but I think we’re headed
in the right direction and not to beat up the providers on the, on the, not the providers, but just the overall
cost increase each year, that’s just not sustainable. So we have to work together
to kinda figure this out. – [Jeffrey] Jeffrey Hill
with Healthcare Business Associates, I’ve been very fortunate to be able to work with a
couple very forward-thinking health plans outside of the
state of North Carolina, who actually got it. They were working closely to help their provider organizations,
whether they primary care, or health systems, to enhance their population health
management activities and patient engagement activities with data, with tools, with
resources, and the like. But interesting, they
were equally motivated to work with employers, who of course were paying the benefits on
behalf of their employees, to get them information on how well or not various types of wellness
or self-improvement programs were working, that they sponsored. And I’m wondering, what
kinds of information would be helpful for
you, from health plans or other forms of payers
that we hear about, not just health insurance companies, but particularly the health plans who are investing in
these kinds of activities, collaborating with the physicians. What kind of information would help you to understand the impact of
those kinds of interventions? As well as how would you leverage that to motivate your employees to choose those healthy lifestyles and programs? – That goes to you. (audience laughs) – Again, great question. (panel laughs) One of the, as a financial professional, we deal with a lot of financial literacy, and one of the things that we incorporate into our financial literacy discussions is the importance of healthy lifestyles, and that health is wealth. And it’s amazing how, if you
have a catastrophic event, health event in your
family, or in your lifetime, when you’re older it can
actually wipe out your wealth. And so, that’s one statistic
that we do incorporate into our financial
literacy, when we’re talking to individuals about long term care, estate planning, setting
money aside for retirement. It’s critical that you’re
as healthy as possible ’cause it will help you sustain yourself and live a comfortable lifestyle. I’m open to receiving more information about what data points are out there to kinda push the envelope
and push the button to get our employees, but
other employer’s staffs more in tune to what’s
happening in this space. So I’m open to suggestions on what data you think would actually resonate with an employer like mine,
or a big employer like SAS. – And if I may, real quickly, in addition to representing
a lot of employers of all sizes, we’re a
23-member employer ourself. And I think what would be helpful is we’ve tried a number
of things over the years and we didn’t set a baseline
before we started it, and we didn’t get data
at the end of a year or 18 months from the folks
that we were working with. So if we’re gonna engage in activities, what baseline measures should we take? Blood pressure, looking
at blood glucose levels, looking at stress, what kind of things should we look at? A good example, we had our
all staff retreat last week, and we had Donald Gintzig
come in from WakeMed and talk to us about the
impact of stress on health. And about how people
engaging in their communities helped reduce stress,
and the number of ways to reduce stress. And you could measure over time how a person’s health changes. So if our organization
was gonna pick a community and go to that community
and work on those issues, what are the things that we
measure at the beginning, before we start, and then
we measure at the end, and if that investment
of time, and service, and folks, what does it look like? And if they’re healthier
at the end of the year by agreed upon measures, that’s
the kind of data we’d like, and the other piece would, and by the way, here’s a check, right? So if you, if you always
align the incentives, you do the right thing, that
kinda change will happen. So we’re running right up
against time right now. Please, a round of applause for our panel. (audience applauding) – Yeah, thanks to all of our panelists, and we haven’t yet solved
all the health problems in North Carolina, you all probably saw Melissa Thomason, who’s a very experienced patient advocate listed on the agenda. Unfortunately, a little
bit of an illness today, but we will continue to work with her. And it was great to hear both
awareness of the challenges, but the push for some
practical ideas to move forward on addressing those
challenges on this last panel, around costs, around health,
and a culture of health. Now, I’d like to introduce the moderator of our next panel, on Health
Care Data Initiatives, Where Are We, and Where Are We Going? This is a topic that’s come up a lot during the course of the day already in terms of being able to support, reform, and track progress. Aaron McKethan is a professor
here at Duke University, at the Margolis Center
and in the Department of Population Health. He’s also worked closely with
the state of North Carolina on developing and supporting these transformative
healthcare reforms, Aaron. – Well, hi everybody. It’s really nice to be here, and I will first say that when
Mark first started talking about hosting this event
back before the hurricane last year, as some of you remember. I told him, I don’t know, my best guess is we’ll get a hundred or so. There’s a lot of conferences,
a lot of meetings, and it’s super exciting
to see, post hurricane, the rescheduled meeting,
just how much excitement there is on the topic,
both here in the room and on the web. So thanks for participating. I’m gonna pick up in just a
second with a panel discussion. But I wanted to frame it. We’re talking about health care data, and I wanna pick up on some of the things that the Secretary spoke to this morning, because, as Mark said,
I had a chance to serve as Chief Data Officer
for the North Carolina Department of Health and Human Services until fairly recently. And I got sort of a glimpse into some of the big challenges around data. I think, one thing is certainly true, that the Secretary mentioned,
is that none of the, virtually none of the things
we’ve been talking about are possible unless we figure out data, and data technology strategy. That gives a lot of people
in this room indigestion, I realize, to talk about data. But I wanna posit, as we
think about this panel, getting it started, that actually, we don’t wanna talk about data per se. We wanna talk about questions. We wanna get the questions right. And when we do that, our data strategy will become clear. When I was at the state, we
had all kinds of consultants that would come in and
tell us, “We have tools, “and platforms that you
oughta buy, at great expense, “to help you organize your data.” But we don’t really want platforms, we want answers to questions. And so let me give you an example. The Secretary was talking
about social determinants this morning, in early birth outcomes. The kinds of things we need tools to help us address systematically, are tools that can actually help us answer meaningful
questions along the journey that she was describing. And an example of that is
that we have 120,099 births in the state of North Carolina in 2017. That’s a lot of diapers, 120,099 births. And as the Secretary
said, about half of those, in 2017, the number was
58,159 of those births were to moms that had prenatal care and delivery funded by Medicaid. So that’s about, that’s about 48%. There’s a few more,
there’s a few more births that Medicaid pays for, but
that’s the count of births for which moms had both prenatal care and delivery paid for by Medicaid. Why does this matter? Well, one of the questions
we’ve been thinking about, in the state, is, well,
how many of those moms that are under the purview of Medicaid, have access to WIC? If you don’t know what WIC is, that’s the Women’s, Infant’s, Children nutrition support program. So the Secretary was
talking about food access. Well, the income guidelines, it turns out, between WIC and Medicaid
are largely similar. They’re not exactly aligned,
but they’re mostly similar. So the question was, we
weren’t talking about data, and we weren’t talking about technology, we were mostly talking about
the answer to the question, what percentage of moms that
get their baby delivered and have prenatal care funded by Medicaid, are on the WIC program
when the income guidelines are largely the same. Well the answer is about
17,000 of the 58,000, so about 30% of those Medicaid births were to moms that were not
enrolled in WIC, right? So that’s about a third,
a little under a third of those moms could go
home from the hospital with programs they’re
probably eligible for, if we can figure out how
to make the data flow in the right way, to the right people, not too much data, not
to the wrong people, but data that can support that kind of very practical outcome. How do we get that number as
close to zero as possible? That’s within our purview, and that’s part of the larger vision. But we don’t start by getting
there talking about data, or technology, or
platforms, or other terms that are used in this industry. We talk about being really
clear about what’s the question, and who’s asking it, and
what information is needed to really make, to bring
those questions to action. So we’re gonna talk
about something like this today on this panel. We’ve got a fantastic group. Here’s three categories
I wanna start with, of questions, the types of questions that our panel will talk about. One type of question, again, the best way to talk about data is
to not talk about data, talk about questions. So one type of question is, how do we know what the biggest health gaps are? How do we know? If we’re gonna design
new payment arrangements, and delivery, care
delivery models, et cetera, and all the things that
we’ve been talking about, how do we know where our targets are? Well we need a specific data strategy that can answer that. We don’t need that data
to be run in real time, we don’t need fancy bells and whistles on that kind of data, we just need to put the right data together, to answer the question,
where are the biggest gaps? Where’s the biggest
variation across the state or across the country? And knowing where all these new programs are supposed to be aiming toward, that’s one category of questions that data and strategy can inform, and from which data and
strategy can be designed. The second category is, imagine
you’re a physician practice, primary care practice in Lumberton, we will meet one in a moment. You are seeing patients every day. You are accountable for
a group of patients, even those that you don’t
see from day to day. You have a list of those patients. Which patients do you need to call? Which patients do you need
to send out a home visit for? This is a different question, and it’s a different question that has a different
implication for data strategy. Here, we actually do need to know something in real time or
close to real time, right? If I’m gonna make calls today, if I’m gonna go manage
patients in the hospital today, who’s in the hospital now? Who’s at the great risk? Totally different data strategy to answer that category of question. Third, and final category of question is how do we know this stuff’s working? We had a great question over
here from Dave Anderson, who talked about the evidence base for some of these wellness programs, and we talked about
ROI on this last panel, around some of these programs. A third type of question
we need answers to that data strategy, different
data strategy can help address is, well how do we know
that a medical home is doing what it’s supposed to be doing? How do we know that a
new payment arrangement is actually working? Again, different, each
of these three categories have very different data
implications and data needs. So I think, as we can sort of eliminate some of our indigestion
in talking about data, if we don’t actually talk about data, and talk about questions
and the types of things that different actors in
the system need to know. So with that, let me, let
me introduce our panel, and as I do, I’ll say, that
as a lifelong Presbyterian, I’ve been ingrained, it’s
been ingrained in me, that every sermon has
to have three points. (audience laughs) So I’ve asked our panel to
begin in a Presbyterian style. I don’t know if they’re
Presbyterian or not, I didn’t ask that question. (audience laughs)
– But if they’ll each get us started thinking about
these questions about data from their perspectives and
these first three points, they’ll each speak for a few minutes, and then we’ll open it up to you all. So, first, to my left and your right is (coughs), excuse me, Dr. Karen Smith. She’s a family physician in
Lumberton, North Carolina, just south of here. She is on the front lines of
seeing patients every day, but she’s also a state, award-winning and nationally award-winning
physician leader thinking about the next generation of how we deliver care. So we’re gonna hear from her,
both from her perspectives on the front lines in her clinic, but also her work, thinking about how we make these practical transitions to support physicians. The second speaker is Greg Griggs. He’s a good friend and leads
the North Carolina Academy of Family Physicians. Again, all of these changes are gonna have a pronounced
role for physician organization, new skills, new capabilities, building on the great infrastructure that has already been laid
here in North Carolina at the local level,
through Community Care, through AHEC, and 20
years of other programs. And so the question that
Greg will bring to us is how are physicians
feeling about all of this? What data, what data needs do they have to be successful in these new models? And the like. And lastly, another dear friend (coughs), I’m so sorry about this cough, Christie Burris, who
leads the North Carolina Health Information Exchange,
it’s called NC HealthConnex, and she’s gonna be describing
some great progress being made here in North Carolina
to put data together, to report these kinds of use cases, and so we’ll get a progress
update from Christie and also tell you how
all that work is aligned with the efforts around value-based care and payment reform. So with that, I’m gonna sit with them, and I’ll invite Dr.
Smith to get us started. – Okay, thank you so much. I really appreciate being here. And I appreciate the fact
that you’ve permitted a family physician to come
and share some comments. We’ve been transforming our
practice since we started, the year 2003, and so every morning we have our practice huddle. We go through our AWVs, our
annual wellness visit work list. We go through our chronic
care management work list. And then we ask the team,
anybody have any issues that need to be addressed
before we get started? And we’re ready, we’re prepared. I enter exam room number one. 75-year-old patient has a
puzzled look on his face. He’s a retired colonel, coming in from Pinehurst, North Carolina, and I’m actually practicing in Raeford, but I do provide service for
all of the southern counties, the southern areas of the state. And I said, oh boy. So we just did this
huddle, we’re not ready, because the colonel says we’re not ready. He says, “Dr. Smith, I’m just frustrated. “I went to have my
surgical procedure done, “and they told me I couldn’t have it done. “I was anxious, I was
ready, I was prepared, “but I couldn’t have it done “because I take a anticoagulant, “and they were not
gonna take me to the OR. “They should’ve been prepared. “I come out of the U.S. Military Army, “we would not have gone to
war if we weren’t prepared.” And so, I said, “I’m glad to hear that”. (audience laughs) We weren’t ready for that story, but we actually had a response. One, we said, “Thank you
for sharing, I heard you, “I’m listening, thank you for sharing.” So what this colonel brought
to us, our attention, was why did they not have,
at the time and the place where he was having
his surgical procedure, the information, the data that he needed, that was so astutely
put into my EHR system, why didn’t they have that information? Why is it that he drove
all the way to the hospital early in the morning, and why
did they ask that question 20 minutes before going into the OR, instead of two weeks
before going into the OR? Why wasn’t that data available
at the time of the service, in the place of the service? And he was right, we
should have been prepared. And he said, “You know, I could deal “with not going into
the OR, because I really “didn’t wanna bleed all
over the table anyway”. But it was the anxiety that this gentleman had to go through, a colonel, trained, the anxiety that he went through. So we understand that. So that data should’ve been shared, it should’ve been bidirectional. It should’ve been my
office and the hospital, we should’ve been able to
see the same information. That data should’ve been transparent. There should not have been
any pieces or components left out of that data, that the hospital could not see in my record and
I could see in their record. By the way, that data should’ve been less than six months old. Let’s think about it. What if he had a fracture? What orthopedist is gonna set a bone on a x-ray that’s six months old. You don’t even need a
clinical degree to know that. You’re not going to do
that, it makes no sense. So the data needs to be live,
the data needs to be timely, the data needs to be shared. And then we have to talk
about process and outcome. Okay, so what’s the process data? Taking the blood pressure,
that’s wonderful, you took a blood pressure. What’s outcome data? Doing something with
the blood pressure data that you just acquired. So that information needs to make sense. That data needs to make sense. And I stopped using the
word interoperability, because interoperability
seems to be defined by the person who’s using the term. We haven’t quite figured it out, and we can’t wait for interoperability because the care of our
patients is today and now. So as our federal
interoperability platform gets lined out, we still need to be able to function today. So using that story,
hopefully, kinda captured many of the components
that we’re dealing with. We can certainly do what’s necessary in health care transformation,
but we need to have the data at the right place, at the right time, for the right person, in
the right hands, thank you. – [Aaron] Thank you
very much, that’s great. (audience applauding) Great job, (speaking faintly). – That’s a little hard to follow. (audience laughs) Especially since she’s one of my members, and one of my past presidents. (audience laughs) So, I wanna do my three point sermon, and try to keep it simple and quick. You know, the first
question that we need to ask when we’re talking about questions, is does the patient have
a usual and continuous source of care. Now, I’ve got the answer
for our business panel before there, people who
have a primary care physician have 33% lower health care costs. So why aren’t they making sure every one of their employees have
a primary care physician? Have a medical home, have a
continuous source of care? Everything we’ve done in
this country is backwards. We’ve fragmented everything,
and I can tell you, if I need a specialist, I really want a good Duke specialist, if I’m in Durham. But isn’t it better for me
not to need a specialist? Isn’t it better in the long run if I don’t have to have specialty care? But we don’t invest in primary care. Every other country invests
much more in primary care than we do, and now we’re
proving it stateside, although this has been known for years. Rhode Island just put in a requirement for their insurance plans to
invest more in primary care. What’s happened, their
overall healthcare cost has gone down. There are some simple solutions, if we ask the right questions. So folks who have a
primary care medical home have fewer deaths from
cancer, heart disease, strokes, fewer ER visits,
fewer hospitalizations. So we need to focus, first and foremost, point number one, on having a continuity and comprehensive care to lower costs and improved quality. Number two, I’m gonna
go on the right time, right place bit here. Dr. Doug Henley, our exec at
our national level with AFP says, “The holy grail of primary care “is having cost and quality data, “and clinical decision support “at the point of care
integrated into the work flow.” Cost and quality data. If she’s gonna make a referral, if somebody needs to go to an orthopedic, and she’s gonna make a referral, don’t you want her to refer
to the highest quality, lowest cost orthopedic surgeon, right? Or whatever subspecialist it may be. So there’s certain key data
elements that she needs. It’s pretty simple. We get caught up in
very complicated things. What are we trying to do? What are our cost drivers? We’re trying to avoid admissions. We’re trying to avoid readmissions. We’re trying to avoid
unnecessary ER utilization. We need to be looking at
the total cost of care. And the important thing that
I’ve not heard mentioned a whole lot yet, it got
mentioned a little bit earlier, is what are the desired
outcomes of the patient, right? What’s the patient want? Especially when we’re
looking at end of life care, and who’s the right person to have that conversation with them? The individual who is their
primary care physician. Finally, point number three. Oh, and unnecessarily and
duplicate age of testing. We’ve gotta know if
somebody’s had that testing. I’ve got another story
I’ll tell at another time on that one. Finally, we can’t overmeasure. We can’t have 83 quality
metrics from Blue Cross, and 83 quality metrics from
each of the Medicaid plans. How many of you can think about more than two or three things
at a time, right, right? Now, physicians are smart,
healthcare providers are smart. But they can’t think of 83
things at the time either. So we’ve gotta look at
what makes a difference. And we can’t have data
contradicting each other. Get their A1C low, because
they’re a diabetic. Well, now their
hypertension’s out of control. We’ve gotta quit treating
diseases, and treat people. That’s why you need a quarterback, that’s why you need a
primary care medical home. We’ve got to integrate all this, and we’ve got to have
the incentives flow down. So remember three things,
do you have that usual and continuous source of care? Having the holy grail of the data, where you can look at cost and quality at the point of care into the work flow. And three, not measuring too many things, measuring the practical
things that are actionable. Why do we measure something
that’s not actionable? We need to be able to act
on that data, thank you. – [Aaron] Great, great, great, Christie. (audience applauding) – Good morning, and thank
you for including me in this very important
conversation today, Aaron. I think we can all agree
that patients deserve to have a complete health
record available to them where and when they need it, and that’s really the crux
of this conversation today. In North Carolina, the Statewide
Health Information Exchange has undergone different
governance structures since its inception in 2011. Yet broad support in the
past couple of years, and multiple shifts in strategy have lead us to create
in state law, in 2015, the North Carolina Health
Information Exchange Authority. We report into the Department
of Information Technology in the Government Data Analytics Center. We partner very closely with
the Department of Health and Human Services. And we are also in a
public/private partnership with SAS Institute, who
is our technology partner. In addition, in 2015, to
creating the HIE authority, and the HIE network, which is
now called NC HealthConnex, a state law was passed
that required physicians who receive state funds for
provision of health services, to submit data, both patient demographic and clinical data, to the state HIE by certain very aggressive
dates in 2018 and 2019. And so I wanted to
give, my first point is, how did we get here, and where are we now in terms of data sharing across
the state of North Carolina? Did you know that North Carolina, today, providers use more than 150
electronic health record vendors in our state. And so NC HealthConnex
is doing the hard work to bridge that gap that exists between all of these different vendors. We sit in the middle, with
a centralized infrastructure and data repository and
become vendor agnostic, to allow providers and
participants, such as Dr. Smith, to have access to that
complete health record at a point in time when she most needs it to care for her patients. As of January, 2019, NC HealthConnex links more than 4,500 health care facilities, including 97 hospitals,
numerous physician practices, long-term care facilities,
behavioral health providers, federally qualified health centers, county health departments,
and we’re working to incorporate laboratories and emergency medical services in 2019. We’ve made significant progress in the short time that
we’ve been at this work, with a significant
investment from the state, and numerous stakeholders
who are sitting in this room. We have a lot more work to do. We have an additional 4,000 practices who are waiting in onboarding,
so that they can also share in this centralized infrastructure, to really promote the shared data that we’ve all talked about today. And it’s not easy, Secretary
Cohen mentioned it earlier. It’s hard, it’s hard work,
and the data is messy, and it’s not perfect, which is why one of our foundational parties
is a data quality program. I just wanna give you a quick snapshot of where we are today in terms of the NC HealthConnex system. In addition to the 4,500 who are live, submitting data to us, we
account for over 41,000 providers who have contributed records. We have over 52 million
continuity of care documents within the repository. We’re serving, again, over
150 unique EHR vendors, and we have 6.7 million
unique patient records. And we’ve also enabled data
sharing across state lines with six border states
and interconnected HIEs with our state. So second point that I
wanted to make to you is that we’ve done a lot of listening, in terms of a lot of data connection work, we’ve also done a lot of listening. And the physicians and
other care providers across the state over the last few years have told us time and again
that they’re frustrated by numerous state and federal
regulations reporting, and all the different places
they have to report that. They’re experiencing
burnout due to the demands placed on them. Greg talked about that, too,
in terms of measurement. And they’re faced with
changing business models. And we know that providers can’t control any of the outcomes here
or improve patient care unless they have access to data, which is why there’s a lot of
health information exchange happening in the state. So we don’t purport to be the only health information exchange. We recognize that Epic
has care everywhere, regional HIEs, and national networks also support the statewide
infrastructure as well. We kind of helped bridge
the gap with this as well with that last model of connectivity into helping that urban and rural divide that exists in our state. This is one of the primary reasons that we serve as a
figurative public utility, we’ve heard that a lot
today, to help connect communities of care
across the entire state to improve more timely data sharing. So point number two is
where do we go from here? The utilitarian image of
HIE making point-to-point connections with current exchange, what do you know about my
patient, this is what I know, and send me those records. We need to move beyond that to support Medicaid managed care and value-based care models. We need to move to the point
that we’re taking this data, taking and improving
the data quality of it, serve as aggregators of that data to provide that intelligence
back to our participants so they have more timely
access and more intelligence. I think we can all agree
that the last thing we wanna give to providers is more data, so we also have to work to make sure we’re providing just what they need to close those health care
gaps, as Aaron mentioned, and also to help them understand what more they might need to know about their at-risk patients. And I echo Secretary Cohen’s sentiment that this is hard and
will require full support of all stakeholders in North Carolina to work collaboratively to
improve the overall health. Third point is that we’re
looking forward, future forward. So it’s not enough just to
meet a state requirement or a state mandate, but
how can we participate in this conversation to
really improve the health and health care in North Carolina? So we’ll be releasing soon a road map that lays out an ambitious
plan for the next three years, for the end-use cases
that we will support, sharing data across the care continuum, to provide meaningful
data, not just noisy data, in the hands of physicians,
care coordinators, and payers, to support
this move to managed care and value-based care payment models. It’s a living document, and will serve as our North Star, as we would like, where we’d like to see NC HealthConnex go as it matures. One final thing, so I
have four points, Aaron. I wanna touch on, is our most relevant to this conversation day specifically, is a recently launched
event notification service. So, had Dr. Smith, maybe
perhaps have that information within NC Notify, she
would’ve already known about the case that could
happen with her patient, or she may have known that
he presented to the ER with blood clotting, because the surgery had already happened. This is a proactive push of information based on ADTs, and also
which is not just acute, but ambulatory events that
are happening across the state to our participants, so that
they have that information in hand when they need it. We believe that this service
will be a valuable tool as we move into managed
care to help payers and providers to really
monitor their at-risk patients. And over time we’ll add
additional convenient delivery methods, increasing
delivery frequency, and expand the data inputs. Challenges and opportunities are many. We look forward to helping
solve these problems. – Great, excellent. (audience applauding) Must say, this is a great
panel of Presbyterians here, good job with that. As you were speaking, I’ve got three, I’ve got a question for each of you, and I would like to go one at a time, my left to right. And after that, you’re invited to come up to the microphones and ask your questions as we dialogue. These three questions
be incredibly practical. The first one to Dr. Smith. Dr. Smith, you’re in an ACO practice, and I would love to know,
this is an accountable care organization practice, but you’ve been, you’ve been in practice for a long time, so walk us, as practically as you can, through what’s different
about being a practice not in an ACO, to being
in a practice in an ACO, in general, what’s
changed, what’s different? And particularly as it relates to data, what else do you need as an ACO practice versus a non-ACO practice,
if that makes sense? – Very good, and it’s
a excellent question. So recognizing that an
accountable care organization is a business model. It is a business model that
we are now working with and engaging in our clinical setting. So I’ve been at Raeford for 27 years, and the practice that I came
out of had 18,000 charts before I arrived. We had a lot of information,
it was all paper. In some cases there were note
cards for the earlier charts. Other cases, notebook paper. So we had a lot of information, and we knew our patients,
we knew them very well. That information also had a lot of data about a lot of people who
lived in that community. But when I was given
volume one, two, and three, and I had a 15 minute
visit, how in the world was I supposed to extract
that valuable information, the data that I needed,
to care for the individual who was sitting before me? So one of the things that
the ACOs have helped us to do is to actually aggregate that information that is most useful, and allowing us to have better outcome
for that individual’s hypertension, diabetes, hyperlipidemia. It’s allowed us to have access to the technology that we
need, our EHR platforms. I’m operating in a system
where I have eight interfaces, just to do what I need for the one person sitting before me in the exam room, eight different interfaces. There’s cost to that. But then there’s this level of efficiency that also comes into play,
that the ACO assists us with. They help us utilizing, the current ACO, utilizing the app in terms of
extracting that information from the EHR binder,
getting it all in one format so that when I have the
huddle with the staff in the morning, we are
actually performing activities based on succinct pieces of data, of information that we
know will have a impact on the outcome of those individuals who come in through the day. The ACO allows us to meet
with other providers, also allows us to intervene
with practice strategies that’s gonna make a difference for that population of
individuals that we’re caring for and allows that level of efficiency. There’s a lot of discussion right now in the terms of provider burnout. I even go to meetings
and we’re talking about medical student burnout. So why are we burning out? Maybe because we’re getting overwhelmed with so much information
and having to repeat and redo information, and
pharmacy benefit plans. I just prescribed that medicine, why can’t they get it
by the end of the day? So then I have to go back through and figure out another medicine that I can give to that patient. And so that information
should be before us, and the ACOs actually help us organize it, get it in a succinct
manner, and let’s now show a difference in the
outcome for the population that we’re caring for. – Great, that’s super helpful. Thank you very much. Greg, let me ask you, my question for you is gonna take a second
for me to sort of frame, but I wanna, the question’s gonna be what do you think most
primary care physicians independent practices in North Carolina are gonna do with respect
to the advancement of a home model in Medicaid? So just be thinking about that. Now, let me unpack that. So, shifting now to the Medicaid program, one of the great, I love
all the new attention that North Carolina’s
getting around the country for all the new things starting, but I’ll point out, so much of it is building on the work that’s gone on in this state for decades. We’ve got an infrastructure,
we’ve got collaboration, we’ve got lots of
innovation that’s happened that makes it possible for
us now to take the next step. One of those is the locally rooted Primary Care Case Management system through Community Care North Carolina. That’s been around for a long time, most states don’t have that
kind of infrastructure, and that’s why the Secretary
can effectively build on that structure by saying
we wanna see care management that happens locally, even as we wanna see those programs evolve. And so undermanaged care,
there’s a new program called the Advanced Medical Home program. Again, it builds on the primary care, the patient-centered medical home model that has been around for 20,
25 years in North Carolina. But it has a few changes as
we moved to managed care. Under managed care, now there’ll
be multiple health plans participating in the program,
as opposed to just the state acting as a plan. And that means we need
to develop a framework through which the medical
homes of yesterday can find their way into
the medical home structure under managed care. And so for the state,
that’s meant defining a set of quality measures
and requiring the plans to stick to those, defining
them in very technical terms. We have, as you’ve just
pointed out, Dr. Smith, we don’t have all these
different measures, at least within the Medicaid program. A common set of measures, a common set of payment minimums, not to get into the wonkiness of that,
but effectively it means the state is requiring plans
to pay certain amounts of money to practices that choose to take on more of the responsibility for taking care of care management of their patients, regardless of the payer
that the beneficiary is in. That should take some of the friction out as well for practices. And the third piece relevant
to our conversation today is requirements around data. Requiring standard, not just
the quality measure itself, but requiring that health plans share data with practices or practices partners working on behalf of those practices, so that in the end you don’t
end up with a Tower of Babel data flow problem with lots
of different kinds of data going to a different practice. All I’m talking about
now is within Medicaid. So as we’re gonna get
this going with Medicaid, but then the question is, and
this is getting to you, Greg. How do we, how do you
think practicing physicians are going to respond to this
in the first year or two, recognizing there’s some
big transition steps. And then the B part of that question is do you think there’s a chance that other payers besides Medicaid could adopt those same ideas, principles of common
metrics, common data flows, even those data flows that don’t live in the information exchange, right? So let me ask you to just
comment on it very practically, how it’s going out
there, and how you think the pulse of the state is
on that, those changes? – I wanna go from backwards there, and say I hope and pray that other payers and other plans will align. Because you can’t have, take a practice, Dr. Smith’s practice has a
large Medicaid population, but let’s take a practice in Durham that maybe has a lot
of commercial patients but only 10% of their patient
population is Medicaid. Now, you can’t start moving this direction for 10% of your population and not move for your entire population. We’ve seen it already. I mean, when Blue Cross started looking at how many people were doing foot exams on their diabetic patients, they found that everybody was doing it. Because that was an early
CCNC Medicaid measure. And so folks were already doing it. And you can’t, it’s
very difficult to treat this patient one way,
and this patient one way, and look at this patient another way. So we’ve got to align, first off. How the independent practices, I think, are going to move, they can’t afford to have five care managers
from five different Medicaid plans coming into their practice, that is just not practical. So they’re gonna have to try to move from what’s called Tier 2 to Tier 3, and I won’t get to wonky into that. But they have some control
over the care management. If you’re Tier 2, the Medicaid plan controls your care management. If you’re Tier 3, you
control your care management. But they’re gonna need help, and I think that’s where they can build on that local community
care infrastructure, ’cause those local care managers already know part of the
resources in the community, and they already know part of
the issues in the community, and they already know
part of the patients. But there’s also got to
be that data analytics, and it’s got to align
with what you’re doing with Medicare for an ACO, it’s
gotta align with Medicaid, it’s gotta align with commercial. So the more we can have data systems, and not just the data flow. It’s one thing to get the
data into your practice, it’s a whole different
thing to make it useful, impactful, and actionable. And so we’ve gotta have
that system in place. So I think that’s got to align. It is going to be tough work. I think our practices in North Carolina are probably much more ready to do it than elsewhere in the country. If you look at the number of
practices in North Carolina and the percent, that
early adopter’s of EHRs. How long have you had an EHR? Since ’03, right? How many primary care
independent practices had a EHR in 2003 along with the country? Not many, we had it in North Carolina. How many practices
elsewhere in the country are already NCQA recognized patients that are medical homes? We’ve got a lot in North Carolina, because of what Medicaid did, and what the Blue
Quality Physician Program did with Blue Cross, but
we’ve got to move beyond that. – Great, and let me just point out one thing that’s frankly
a little self-serving, and nerdy, but I wanna
point it out anyway. So this difference that
Greg was describing between so-called Tier
1 or Tier 2 medical home within the Medicaid construct, that basically means, look, I’m a practice that’s pretty busy, I’m
happy to let the health plans handle all the care management, I’m just coming in to see my patients. If that’s your bucket, if
that’s where you are on day one, that’s a Tier 1 or Tier 2 practice. For Tier 3 and Tier 4, Tier 3 practices, which are the ones that
Greg’s talking about, that switch from Tier 2 to three means, no, no, I would like
to define a common way of thinking about care management for all my Medicaid patients, regardless of whether.
– For all your patients. – Well, ideally, yeah, absolutely. Regardless of whether they’re enrolled in, now that we have the health plans, I can say whether they’re
in Blue Cross Blue Shield, or they’re in WellCare,
or whatever they’re in, I want a common way of doing it, and I need common data,
specifications and feeds, that look the same with common
quality metrics across them. And so I think that difference is building on the infrastructure we’ve got, and it’s gonna have some
friction as we get started, but it’ll be exciting
to see how it plays out. Now, Christie, to your
question, then I’ll open it up for everyone if that’s okay. So Christie, you described,
we’ve been thinking and planning for HIE for a while, and now we’re making
some real, the gas is, I don’t know what the metaphor is, but we’re making good progress here, partly because the legislature now requires provider participation, that certainly moves things along. But I wonder if you could convey, again, in the spirit of these,
all these questions, very practically, year
one, say next year, 2020, 2019, 2020, call it year one. What can a practice expect from the HIE? What, of all the types of
potential types of data that could be available,
what’s the most important kinda data that practices can expect that’ll be up and ready for them, you mentioned the
notifications for example, versus, say, five years from now? Because five years from
now, you could imagine claims data flowing through the exchange, social determinants data, a whole bunch of other kinda data sets, but in the spirit of taking it slow and picking some use cases
that are really widely needed. How do you see that kind of progression of the next few years? – Yeah, so, yes, there’s
nothing like moving from please share your data, to
you must share your data, to help break down some data silos and get data flowing across the state. So that’s definitely well-positioned NC HealthConnex to be
prepared to support physicians and other health care
providers across the state. We have a clinical data repository, and within that data
repository we make available what we call, what aligns to
the common clinical data set. So you’re gonna find patient
demographic information, their vitals, immunizations, lab tests, those very basic but very
important information about a patient. And in terms of what they’re
gonna need in the next year, as you move into managed care, we do feel like NC Notify will place the ADT data, plus what’s happening in the ambulatory setting in the hands of our participants so that
they have that actionable data, and it’s of no cost because of the state’s significant investment
in this infrastructure, it’s of no cost to participants, that’s part of our basic service. We talk about can we utilize, as we grow, in three to five years,
additional data integrations that you referenced. Of course, working with,
we’re gonna be integrating with the Controlled
Substance Reporting System. We’re working with the
immunization registry, we’re looking at the CARE360 platform, is there a possible integration there? Additional national
integrations, like I mentioned, we’re integrated with the VA, we plan to integrate with the DoD. So I think just the depth and breadth of the data that can be
pulled into one repository, and then perhaps using a
clinical intelligence engine on top of that to use that data to send to the trigger, so
that we’re pushing information to Dr. Smith on her patient, so she’s not having to go look for it. So that’s where we see ourselves. – [Aaron] Great, okay, I
see we’ve got a queue here. So I’m gonna start on this side. If you ask your question.
– Okay. – [Aaron] And you could fire away. – [Harvey] I’m Harvey Estes, and I’m probably the
oldest guy in this room. (audience laughs) I’ve watched it for a long time, but let me point out some facts that are, I think, relevant. Number one, when you ask patients who leave the doctor’s office today, not a doctor’s office, more
likely a clinic in a hospital, what their chief complaint is, and they will tell you,
the doctor was talking to the computer and not to me. So, fact, the data system can interfere with good patient care,
and Karen Smith knows that. The second observation is
that if you ask the doctor what the biggest complaint
is, it’s the fact that I have to collect all this data which is not relevant to
this particular patient. And the third fact, there’s
no representative of Varik in this room, which
provides the basic framework for most big health systems in the state. And there’s no accountability. And anybody who is aware of
the health care data system, will tell you that it was constructed for the accounting office
and not for patient care. It still is. My suggestion is that we ask the people who profit by the health care data system, have objectives that they must meet and the practicing physician have a short list of a few things that they would like to achieve, and make the data system payment
contingent on the ability to meet those objectives, thank you. – Great, great. (audience applauding) Great comments, Dr. Estes, thank you. Any comments on those? – I would certainly agree, and as we are in a process for transformation, let’s make use of the comments, and listen to the patients. Put them back in the center. We are also patients. Put it back into the center in terms of are we
addressing our own needs, as we transform, and we
do practice modification, and we make changes, make
sure we’re paying attention to the patients. – [Aaron] That’s Greg now. – And as we’re collecting data, let’s give the primary
care the resources to do it so the physician ain’t
necessarily having to do it, maybe it’s a scribe in the room, maybe it’s someone else. And let’s be very careful about
what data we’re collecting. Are we collecting data
for academic research? Are we collecting data for
the sake of collecting data? Are we collecting the data that is needed to provide the healthcare
that’s actionable that can change the
trajectory of someone’s life? – Great, next question, over here. Would you mind saying your name. I won’t ask you to do Presbyterial roles, but at least, tell us where you are, and who you are and where you’re from. – [Heidi] My name is Heidi
White, I’m a geriatrician. I take care of older adults. I’m on faculty at Duke. I get to do a lot of different things. I get to move from a very
robust electronic health record called Epic within the Duke system, and then I get to go to nursing homes and take care of patients
in nursing homes. In the health system we called them skilled nursing facilities. But most laypeople still
call them nursing homes. And most people, over the age of 65, get to touch a nursing
home in their lifetime, and most of the people in this room will get to be in a nursing home for some period of time, most
likely for post-acute care. This is where we do the vast
majority of post-acute care after hospitalizations now. And the problem that exists
in these nursing homes is that, for the most part,
they are completely disconnected from the Duke Health System,
from the UNC Health System, from the WakeMed Health System. And they’re trying, in this area, I get to work with the ACO too, (laughs) and they’re trying to deal with all of these
different health systems. They have presently very rudimentary electronic health records. Myself, as a physician,
I go to the nursing home and I log into the nursing
home electronic health record. And then I do my documentation in a different electronic health record. So they’re separated,
and then I have to log into the Duke Health System to see things. The nursing home is asked,
the nursing home staff is asked by the three
major ACOs in our area, all of which use Epic, to log into three different entry points to get information on their patient. And they can get a lot of information. They can get primary care information, they can get hospital information, they get a lot of important information, but they have to log into three, even I, within the system, I
can see what’s happened at UNC, I can see what’s happened at WakeMed, but they can’t. They have to log into
these different systems. So I’m so excited (laughs)
about HealthConnex. I’m excited, I wanna hear more about what you’re doing to
connect to post-acute entities like nursing homes, and
home health care agencies, and hospice agencies, all of
these really important aspects of our health system that aren’t getting very much attention and
who have rudimentary access to electronic health records now. – Great. – Thank you for that question, it is of great import to us to really work with this community of
health care providers. We’ve spent a lot of time with them, and we do have significant numbers of long-term care, skilled nursing, and hospice providers
who are moving forward in the connectivity process. And they are, and we’re
meeting them where they are. When you talk about the
different technology, they not be able to send
as robust of a data set as, say, the health systems we work with here on Epic. So it’s a meet them where they are, and take in the data that
we can receive from them, and really help them
understand, on the reverse site, within their work flow, what
do they need back from that, because we obviously are presenting back the health system data as well. They are very interested
in the Notify product, so that they can just
receive a notification that this has happened,
and they can act on it. – [Heidi] Right, so a lot of information that you’re collecting,
just like flu vaccine. They really need to know
when people are coming in, who got the flu vaccine. And if they can get that
kind of basic information, it will really help to streamline
some of their processes, and improve care overall in
these facilities, thank you. – Great, yes ma’am. – [Barbara] Yes, I’m Barbara Brandt, I’m Director of the National Center for Interprofessional
Practice and Education, based at the University of Minnesota, but I live in North Carolina
from December to April. (audience laughs) Anyway, I won’t go there. But I just wanted.
– It’s basketball season. – [Barbara] My healthcare
provider is in Minnesota. I have my chart, it does
have interoperability, and I can, I have access
to all my lab values when they come in. If I’m concerned, I type in and talk to the nurse practitioner, the PharmD, my primary care physician. I had to go to an orthopedic
free-standing urgent care. They had access to all my meds, as I had to have a, I was in one hour for a dislocated toe, in and out. They had all the information there. So I wanna cheer you on. This is a great system to aspire to help patients
manage their own care with their team of providers. And I won’t get up and
ask one more question, but I actually wanna know,
how is higher education going to be engaged in
this, and so that students and residents get access
to your innovations while they’re studying, and becoming professionals, thank you. – Well, let me tackle that last comment by just saying, having spent
a lot of time in Chapel Hill, go Heels, and also, now at Duke, go Duke. (audience laughs) Just for the respect of basketball. One thing that’s exciting
to see is that in many ways, the people who are being trained, in not only clinical medicine, but we have just extraordinary
leadership in the state among the nursing community,
the pharmacy community, other allied health professionals. In many ways, those who are training are actually, in many ways,
leading the use of data. They grew up in a world of Google. They don’t tolerate friction,
standing in their way of getting the information they want. Doesn’t mean that it’s easy, but I think, as we design these systems
here at Duke and UNC, often we’re looking at sort
of the renegade students, and resident, and nurses
who are the professionals of the future for our system. And it gives me, it gives
me a lot of encouragement and a lot of optimism about where we’re going here with data. – And I can echo that as well. I actually have a student with me now, and so, and we have several
students in our office. So we wanna make sure that
we have that connectivity from those who are a little
bit more savvy with technology and those of us who are not, and making sure that we are addressing all of our care population. I could also tell you,
yesterday we were fortunate. We provide medication assisted
treatment in our office and we’re utilizing services and special procedures
from the North Carolina Medical Society Foundation, and yesterday we did a telehealth visit
with one of our patients who is struggling with
opiate use disorder, a whole lot better now. But we evaluated her, and she was at home, and I was in the office. So we’re introducing
more of the telehealth, we’re utilizing the patient portals, and we’re making it work. And I’m in rural North Carolina. So we are definitely putting the pieces of the puzzle together. – [Aaron] Okay, any comments here? – Yeah, I will, the two
parts of the question were just talking about data exchange and again between the more
urban and rural divide. Just that we had a recent participant reach out to use to say
that she had a patient in her office in Raleigh, who
had been in a car accident in the eastern part of the state, and had been transported
to the emergency room and we could not remember
which hospital it was. And so, she just
overheard the conversation happening before she walked in, and quickly looked it up and
was able to find that out. And so, there is utility in being able to, no matter where your patients are, being able to have that data available to help inform their care. And then we would welcome working with UNC and Duke on this, but we’ve been active with ECU Medical School this year, and I’m presenting to
their medical students and their internal rounds, and they keep coming and asking
us to come back for more. So I do think this is a
really noteworthy topic and it’s where we need to be going in terms of educating
students and residents, and the value of data sharing. – [Aaron] Great, yes. – [Peter] My name’s Peter,
I’m a medical student, so I’m really glad you just
asked that question, actually. (audience laughs) So I’m a medical student at Duke. I’m in the primary care
leadership track here, and I have to say, I really
liked one of the words that you just used, which is renegade, and just from my perspective, it still feels like you have to be a little bit of a renegade to
wanna go into primary care. (audience laughs) – We’re changing that. – [Peter] I know, and that’s my question, is, what, you know we have, you
just mentioned all this data about the importance of primary care, and yet it still doesn’t
feel like a priority for some parts of our health system, and it doesn’t feel like a priority for students who are going
through medical school. So how do we bridge that gap between, we all know the data around this, and yet people are still not incentivized or interested in going into primary care. – I think one of the things
that’s gonna happen really soon is as we, you know Blue
Cross just announced with five other health systems, a shared risk, shared reward model called Blue Premier. As those systems, like at Duke, and no disrespect to Duke, but I know that Duke doesn’t
put out many physicians who want to go into primary care. So I’m glad to see that
you’re in the primary care leadership track, let’s keep you there. (audience laughs) Come to our annual meeting. (audience applauding) But, as they start to see
that they’re responsible for the total cost of care, whether it’s Medicaid managed care, whether it’s the Blue
Premier type of thing, I think they’re gonna start saying, whoops, we better invest
in keeping people healthy and in prevention, and I
think that’s gonna change. Data changes everything. Right now, it’s hard to even determine what the total cost of someone’s care is. It’s hard to determine whether
quality metrics are met. I think data is gonna empower folks to realize that we’ve got
to invest in primary care, and I think you’re at
the tip of the iceberg, so stay the course. – Amen to that, let me
just, speaking of data, I’ll just say, to build on that point, Medicare’s seeing it too. We’ve been talking about Medicaid, but as part of the Affordable Care Act, the ACO concept, the initial program which is called the Medicare
Shared Savings Program, and now we have multiple years of data to look at how it’s going. And you can roughly, for
the sake of conversation, you can roughly break the
world into physician-led ACOs, that is ACOs for which there’s
not a hospital in the ACO, and so the goal is coordinate care to avoid hospitalizations
anywhere possible, and system-led ACOs, or
ACOs in which hospitals are a big part of the system. And then that’s one dimension. The second dimension is how
long have you been an ACO? Do you really see a
change happen in year one, regardless of what type of ACO you are? And so the net result of all that is that the ACOs that are doing the best are those that are physician-led, and that have been in the
program for two or three years. It does take a while to learn how to use these new systems, to think
about better coordinating with nurses, pharmacists, care managers, at a population level rather
than just the patients in your practice,
orienting yourself to data, et cetera, et cetera, and
learning how the care delivery changes have to be made,
but the data are in, and they’re positive, they’re showing that physician-led ACOs
that stick with it over, year over year, actually are
the best cohort of practices, and I think that speaks to the renegades will become the mainstream,
if that data carries out here in North Carolina. – And it’s not just
physician-led, it’s primary care physician-led that are leading the way. – Yeah, amen. – When we look at the
value-based payment systems and the models, and the
ones that are successful that you have just alluded to, it really does start
with the building blocks of the primary care physician. When we talk about access to care, when we talk about quality of care, when we talk about the
efficiency of the care and the cost of that care,
it is that interaction between the doctor and the patient, and the systems that have
been created with that unit that are found to be most effective. And when we look at the triple aim or the quadruple aim, it
is that basic foundation, what you are learning as a student, your interaction with the patient, and you as the provider of care,
that is the building block. So you’re in the right mindset, and I encourage you to
remain in that mindset because you are the future. – Great.
– Thank you. – So, I’m gonna go to your question. I think we’ve got about seven minutes? Five, five minutes, so we’ll be quick. I just wanted to just,
I’ll be remiss not to say, I think the next generation, and I hope the next panel
can get into this too, independent primary care,
or primary care physicians, practices, and ACOs, in
conjunction with behavioral health, because there’s so, regardless
whether you’re at the VA, or in a non-VA facility. VA gets a lot of heat for
not having good access, but in this state and around the country, we have a long way to go,
whether it public or private, to coordinate better and get patients in who need a basic
behavioral health services, I think that’s an alliance that
we can see a lot more from. Your question, sir. – [Amir] Hi, my name is Amir. I’m a data engineer with Nuna Health, a San Francisco-based health
care and tech company. Secretary Cohen talked about understanding the impact of interventions across social and clinical determinants. How can the state’s data strategy, Medicaid or outside, and
now to give an example that, how can a state’s data strategy help give a holistic view of data, and help agree on measuring
outcomes that are useful? – Okay, so there’s a lot of information that is aggregated from
the state standpoint, and we know that we have our five entities that we’ll be working with. That information is valuable. There’s information that we didn’t have available to us previously. And that was the health
risk assessment data. The data that captures the
social determinants of health. The data that really makes a difference, because now we’re at the patient level. I can write prescriptions,
or EScribe prescriptions all day long, but if the person has no way of obtaining their groceries at home, rest assured, those
prescriptions are going nowhere. The blood pressure will not be controlled, and their source of care will turn into being the
hospital or the emergency room. And so to capture all of
that information together, the information that really matters, do they have access, do
they have transportation, the information that the state has, the zip code data, all
of that, put it together, and now let’s sit here before that patient and say, I understand
you’re having difficulty with just eating food at home. What can we do to help address that? I am so excited about what the secretary discussed this morning,
and I just can’t wait to get back home and find
out who’s in my little area, because that, to me, is really what’s gonna make a difference. – I’ll just comment, too,
that I believe that over time, NC HealthConnex will help measure
the impact of these things because we’ll have the
longitudinal clinical data to support change in health. And so we just look forward to, and are poised to working
with DHHS and physicians. – Yeah, you heard me,
I’ll give you a last word here in a second with the last question, but you heard me at the
outset here talk about how we should really not talk about data, as we think about data strategy,
but rather ask questions. And the Secretary’s asking
an important question. She’s mandating that every
health plan ask the question in a systematic consistently specified way about social determinants. And so, what do we do
with that information? There are some plans in the near term, but I think, just
gathering the information and asking the question will mobilize us to figure out what the big hot spots are, where the biggest need is, and connect the resources accordingly. So you’ll have the last
question, hope it’s a good one. (audience laughs) – [Rachel] Rachel Greenup,
I’m a breast cancer surgeon and health services research at Duke, and in terms of quality measurement, we’ve done some work in
national cancer care, showing that process
measures at the patient level work well, but when you back up, they fail to discriminate
hospital performance. And also, that these
externally imposed measures don’t account for what patients want. So how do you envision using this data to give real-time feedback
back to doctors and hospitals to change what they’re doing so that it impacts patient outcomes? – You wanna get this?
– Go for it. – When we think about
managed care, specifically, the outcomes and the measures that they’re gonna focus on
the first couple of years is claims-based. There are some hybrid measures
that they’ve released, and so we’ve been working with them to understand what that will be, but we need to prepare our system to look at those measures and to make sure that the data that we’re
asking to be received is that data, that we
have those data sets, and then that we can
look at it, aggregate it, normalize it, and so we can give that back in a variety of means,
and that’s looking at it through perhaps a notification service, or perhaps just data as a service. There’s different ways to look at that, but that’s definitely a
strategy that we’re following over the next couple of years. – And when we speak about
the process measures versus outcomes, and even
looking at what physicians have just gone through,
our first round of MIPS, we know that it was a higher value placed on outcome measures as opposed to the process measures. And that was what I alluded to. Yes, I have a blood pressure,
great, you obtained it, and you did it correctly. What does it mean? What does it matter? And what can I do with that? And that’s where the ACOs and a lot of our clinically
integrated networks and the collaboratives of working, how can we help this provider group, this team to strategize,
to make a difference with all of the data and information that they have available to them, so that we will have an impact on outcome. – And, you said something very important, what does the patient want. And I wanna go back to that. If we don’t start
measuring patient desires, how can we really say we’re
getting great outcomes? There was an Annals of
Internal Medicine study a few years ago, looking at diabetics, getting their AIC lowered,
and more of them were dying. That’s not a very good outcome. The A1C was lower, but
their cardiovascular disease was out of control because we weren’t looking at it holistically. So we’ve gotta make sure we’re
looking at it holistically, but we’ve also gotta look at what outcome is the patient looking for,
and somehow build that back in to what the payers have
and to what’s in the HIE, and what’s into the EHR. ‘Cause if we don’t start
focusing on patient desires, we’re missing the boat. – Great, well this has been a great panel. I’ll just say, to wrap it up, that we are a state
that has a lot of assets that we’re building on, as we
make this inflection point, we’re building on a robust
primary care structure, we’re building on lots
of health professionals around the state, lots of organizations too numerous to name, and that’s
gonna make it all possible to take us to the next step. But the data challenges,
they are big and real, and we’ve got to sequence our expectations and sequence our plan so
that we start by walking, and then move to a gallop,
and pretty soon a run. And listening to renegades to give us a picture of the future, but also listening to people
who’ve been there and done that at the same time. So with that, I wanna thank
the panelists to my left and invite you to lunch
right out the door there, which is where we’re headed now. So join me in thanking our panel. (audience applauding) – Thank you, thank you. – My thanks to the panel as well, and also to all of you
who are asking questions, tweeting, and getting engaged
in this overall effort. Please do head for lunch. Don’t wait to listen to me any longer, because we are finally taking a break, it’s just not that long of one, so we’re gonna reconvene here at 12:45, feel free to bring food
back in if you’d like, and we’re looking
forward to our next panel with another set of health
care leaders in the state on care and payment transformation. (audience chattering) – Good afternoon, we’re
going to try to get started in the next couple of minutes, so I’d appreciate it
if everybody could get whatever they need to get, and go ahead and take their seats. For those of you who are
joining us on the web, we’ll be starting in about two minutes. (audience chattering) – [Man] You’re doing well. – [Man] Oh, thank you I’m good. I’ll see (speaking faintly. – [Man] Don’t step off
the back of the stage. – Are you gonna take the first one. – [Man] I have multiple ones,
not that (speaking faintly). – Well, have a good one.
– I’m not. – [Man] Yeah, it came this morning. I, listened to the
presenters this morning. – [Man] How long was this? – [Man] About an hour and a
half, it’s about two to here, (speaking faintly). It depends on how you can
get to downtown Raleigh, in an hour 40, you know
an hour and 30, minimum. But the.
– The mic is on. – [Man] The drive in at 7:30 is a bit. – [Man] How can I help you with this? – [Man] Do you live in Chapel Hill? – [Man] Yeah. – [Man] Yeah, I sent it to our board. – [Man] (speaking faintly) town,
it’s an easier explanation. – That one seems well done.
– You worked here. – [Man] Right temperature. – How nice.
– This is rolling. – [Man] Oh my God, that’s great. – [Man] Helped me move, (speaking
faintly), I’ll come down. – [Man] That’d be great,
(speaking faintly). – [Man] Yeah, we’ll work file. – [Man] Except you had to go
visit the (speaking faintly). You have a whole nother
system, but I’ll be there. – [Man] I totally understand. – [Man] Oh, next blunder. – Good afternoon, good afternoon, everybody still with us? – [Man] Good afternoon, good afternoon, Mark.
– Thank you. (laughs) I’d like to welcome you all back to our first keynote
session of the afternoon on Payment and Delivery
Reform, with perspectives from leaders in health systems, insurance, and people with policy experience, too. And we brought together a
lot of different perspectives during the day today, and again, I can’t thank you all enough
for the good questions and comments that you all have brought to this collaborative dialogue. In this session we’re gonna try to build on the issues that were
raised this morning, starting with Secretary Cohen, all of the different perspectives
we’ve heard from business, from smaller practices, from
community organizations, and health care providers, and people who are close to patients and helping give them a
better experience and care that really responds to their needs. As people have emphasized,
that’s what these reforms are all about. We’re gonna talk about payment reform, the people who are up on the stage here in the midst of changing
their business models. We heard about that a
little bit this morning from our other panelists, talking about how an ACO, an accountable
care organization is really a different business model, but about the purpose of improving health and lowering costs of care too. And we’ll try to get in,
as we’ve done this morning, to some of the challenges
in getting there, and how we can overcome those challenges in transforming care in North Carolina. So, I’m very pleased to
be joined on the panel by Carmen Hooker Odum, now
at Cardinal Innovations, where she does a lot of work
on community-based innovation and improvement in health and health care, formerly secretary of Department of Health and Human Services here in the state. So, a long history of experience around health care
reform and transformation in North Carolina. Also, please be joined by Wesley Burks, still relatively new head of the UNC Health Care System, thanks Wesley. And as well, by Patrick Conway, the CEO of Blue Cross Blue
Shield of North Carolina. You heard the Blue Premier initiative, or set of initiatives
mentioned this morning. And Michael Waldrum, Mike
is the CEO at Vidant Health, which has been, as you’ll hear, involved in a lot of efforts around community-based care reform. And certainly not least, Gene Washington, the CEO of the Duke Health,
University Health System, who has had, I think, a
career-long commitment towards population health
and using better evidence to improve health and
address health disparity. So very pleased to have you all with us. We’re gonna start with
some opening comments from each of these
leaders about their take on where we are, the foundation
that we’re building on, and the steps that they are taking to try to make the most
of this opportunity to improve and transform health care. And I’d like to start with Carmen. Carmen, you were health
secretary, just a few years ago. But you’ve been involved in health care and health reform in North
Carolina for quite a while, and we’re gonna start with
you for that perspective. You’ve heard what was
discussed this morning. Your sense of where we are, and the big opportunities, and maybe some of the challenges ahead. Please go ahead. – Great, thank you Mark. And it’s been really wonderful
being here all morning and listening to all the good news about the new, new North Carolina. And I would be remiss,
given my previous position, if I didn’t acknowledge
the new, new Secretary of Health and Human Services, Mandy Cohen, and I wanted to congratulate
her and her team for all the work she’s doing. But I also wanna tell all of you, from first hand knowledge, the thing that she needs
most is your support. She needs constructive suggestions with realistic solutions, and she needs the legislature
not to change everything every year, so if there are
any legislators still here. (audience laughs) (audience applauding) – [Man] Quick, really
simple and straightforward. – To follow the last
panel, and Aaron’s request about three comments, I actually do have three comments myself, and I’m gonna run through
them fairly quickly because we were told we
only had five minutes to make these opening remarks and it’s pretty hard
for a former politician to put anything into
five minutes, so anyhow. So the first issue I wanna
talk about is inclusion. And I’m talking now from my perspective of being on the board of
Cardinal Health Innovations, many of you know I was the secretary when this whole mental
health thing first started, and now I’m sort of down
at the community level and seeing it from that level. But none of my remarks should be taken as any kind of official position
by Cardinal Innovations. So the first issue is inclusion. And as we’ve heard the
equation, and value, and value-based purchasing
is cost relative to outcomes and obviously accurate rate setting, accurate service definitions are key. But equally so are the outcomes that, at least in behavioral health, are very deep and confounding. Outcomes in MH/IDD and
SUD are not the same as the physical, medical,
clinical outcomes. And if you’re really gonna quantify value, in my opinion, it is absolutely important that you establish outcomes
that are relational to the circumstances and experience of the tailored plan members. The value-based purchasing is
a relationship-based model, it’s not a fee-for-service model. And you cannot have
true and honest outcomes if you do not include
lived experience people in the design and the evaluation of the metrics and the
measures that are used to determine value. Lines of communication must be made, must be kept open to everyone in the lived experience community, and especially those who have wildly different opinions of yours and may express themselves
differently from you. I know the secretary said
that she was getting people to teach them how to speak
that we can understand them, and I think what we ought to be doing is getting people to
teach us how to understand these folks in our community. So we must look to community leaders to move these ideas forward, and not just the formal community leaders, and I know all of these people
are working in communities. But we have to include those who historically had been
excluded from decision-making, not because they don’t have good ideas, but they’ve been excluded, and they have deep and
really important insights. So that’s the first issue. Second is network adequacy and the issue of community providers. Now in this new integration
model, the LMEs, the tailored plans, The LME/MCOs, are responsible for network adequacy. In order to be included in the networks, providers have to meet
certain quality standards and accept the established rates. Tailored plan members
will have care managers, and we learned about the care
managers from the secretary, though they’re not affiliated
with the tailored plans or the LMEs, and those care managers are gonna help the plan members navigate among the providers,
both in the fiscal world, in the standard plans,
and in the tailored plans in the behavioral health world. In my opinion, this design could result in a lot of small providers
being pushed aside. In the behavioral health world, there are more single
shingle cottage providers and in the street community providers than in the fiscal space. These providers are the
ones who are most tethered to their communities. We cannot suck the soul
out of these providers. Yet many of these
providers are not skilled in developing and negotiating contracts, and heavens, after we
learned about the data stuff, most of them don’t have scaled up provider information systems, most of them don’t even meet meaningful use standards. Yet these providers provide
that social connectiveness to consumers and families
that help nurture the most important thing in their lives, which is belonging, safety, and stability. And these providers may
be, in the final analysis, the ones who actually bring value to this value-based equation, and how are they gonna share
in those value savings? So we need accountability,
there’s no question about that. But we cannot lose these providers. And so I am suggesting
that we develop a third, a trusted third party, or
a partnership organization, would work with these providers so that we can combine
flexibility and accountability and really have value
within the communities. And then the last thing I wanna do is mention, and this
is really specifically to the tailored plans, and the LME/MCOs, and that’s about state-only funding. Now this doesn’t directly impact the standard plans
right now, but it could. There has been a woeful lack of commitment by the legislature to
the single-stream funding for the uninsured North Carolinians who are trying to navigate through the behavioral health system. And that money, the single-stream money goes to the LME/MCOs, and will
go via the tailored plans. So the legislature over the last year has been severely cutting the money to the LMEs for the single-stream funding for the uninsured. And the theory they espouse
is that the LME/MCOs can just backfill these
cuts with their reserves. But as we move into this new integrated behavioral health plan
with physical health and the tailored plans,
and the standard plans, right now LME/MCOs need
reasonable solvency requirements and they need cash available
so that they can get ready to be tailored plans
and have the structures to be successful. And that must begin now. Of course, one solution to this would be, as the Secretary said, and everyone in this room applauded, would be to pass Medicaid expansion so that those over 150,000 people who have behavioral health challenges would actually have access. But at a minimum, if that doesn’t occur, we need to urge the legislature
to stop this funding cuts and fully support behavioral health for our North Carolina
uninsured neighbors, thank you. – [Mark] Thank you very much. (audience applauding) Thank you very much,
Carmen, for getting us going on a number of challenges
that we’ll follow up on. So I’d like to turn
next to Patrick Conway. Patrick worked at, we
worked together a lot when you were in a national
leadership role at CMS on payment reform. You brought that same kind of action here, even more so maybe, to the state level. And I know you wanna talk about some of the big payment reform efforts that Blue Cross is undertaking
as one of the largest private payer in the
state, to drive the changes that have been the focus today. But I know you also realize that it’s not just about the payment, it’s really about changing the
whole way of doing business and way of approaching
health and health care. – Yeah, thanks Mark. And great to be on this panel with friends and colleagues. So, Blue Cross North Carolina, I’ve been there now 17 months. And really what we talk about as being a model health plan
or a model of what’s possible for the health system,
really working with partners, like providers at this table, to really drive change
in the health system to achieve better quality, lower cost, and exceptional experience. We’re doing that in lots of ways. I will adhere to the time limit or less, but will share a few. I was, we were talking
right before coming up here. I’ll be working this
weekend at UNC Children’s, as a volunteer attending, so I’m maybe your highest valued doctor. (audience laughs) You don’t get to pay me,
but I get to bill for you. (audience laughs) – [Man] You pay for what you get right? – (laughs) Yeah, yeah. But in all seriousness, I will, I almost guarantee you
I will care for a family whose child fell through the cracks, had either a social issue
that wasn’t addressed or a complex medical condition
that wasn’t addressed, off and on Medicaid, some uninsured, others commercially insured. And our system must do
better to support people so they can achieve those
better health outcomes at lower cost. So first in the value area,
we did announce Blue Premier, with UNC and Duke, and I think hopefully Vidant soon as well. All these things are on different cycles. But it’s a full partnership model. We are jointly accountable
for quality experience and total cost care for
a patient population. It also allows us to do things,
we’re having discussions, could you turn off prior authorization? Who’s gonna do care management? What’s the data that you need to succeed? How do we get you all the
data you need to succeed, and vice versa, if
there’s some clinical data or things we need, how do we have that real partnership
model and sharing of data and information model. As Mark alluded to, and it was written in your Health Affairs
blog, we’re in the midst, with Blue Cross North
Carolina and the state, and the providers in the state to have the fastest, largest shift to value-based payment, I
believe in U.S. History, I’m not aware of any other state that’s moved at this pace. A lot of work to do. Signing a contract is not a win. A win is when we achieve
the results we want on better health outcomes and lower cost, but really excited about that partnership. And the primary care arena,
with family practice doctors, with Aledade, which is a company that’s helping us provide
support to primary care. We are deeply committed to partnering with primary care
clinicians across the state, giving them the data and
information they need. We actually have a goal to
have primary care payments 10 plus percent of our overall payment, so really paying more into primary care, and a population-based model, where over time, over half of the payments are for caring for the population and not in a fee-for-service model. Lastly in value, mental
health, behavioral health, and substance use treatment,
we announced a partnership with a company called Quartet, with integrating mental
and behavioral health care into primary care. We are using Telehealth and
the collaborative care model today, I think you’ll
see us do more of that. We’re looking at a substance
use treatment partnership that would deploy new evidence-based substance use treatment
capacity into North Carolina because we need it. So we wanna be one of the best mental and behavioral
health plans in the country, if not the best, if possible. The good and bad news there, is the bar is unfortunately
relatively low, I would argue, historically,
in terms of health plans, successfully addressing all the needs in mental and behavioral health. In the health arena, we
invested over $50 million last year in social
determinants of health, things like food
insecurity, transportation. Actually was on an email
exchange with my CFO today about how could we take some of the money we put into fixed bond investments today and invest in affordable housing. So we are able to help solve some of the affordable housing
issues using our capital. Food insecurity is a
board level metric for us, meaning it drives my compensation and all of our executive compensation. And food insecurity for the entire state, not just the population we serve, but the entire state. So how do you move food insecurity, partnering with the state, with providers, and improve that for an entire state. Last example in the improving health, in diabetes we’re looking
at an array of partners where we think we could
take 10,000 or more people with diabetes through complex
behavioral modification that’s evidence-based,
literally cure diabetes. They no longer need a medicine, their hemoglobin A1C is
normal, you’re really moving population health outcomes at scale. So those are just the
few things we’re doing. I do think, I challenge us all. We’re gonna need all
the people at this table and in the audience, and lots
of others across the state. I think we’ve got a lot of
work to do in front of us. I think we’ve made significant progress in North Carolina, but
I think we really could be a model of what’s
possible for the nation, and we can only achieve that
if we do that work together, collectively, on behalf of the people in the communities we serve. So thank you.
– Thank you. (audience applauding) – So Gene, and I wanna
hear from the rest of, the other two health
system leaders here too. Some big changes coming
from Medicaid and the state, some big changes coming from Blue Cross in terms of payment, in
terms of support for care. I know Duke is taking a lot of steps to make the most of, and lead
in this opportunity as well. – Yes, thank you Mark. First of all, as Chancellor
for Health Affairs at Duke, I do wanna welcome you to Duke. We, at Duke, we’re taking great pride in the notion of this
concept of Duke health, and so while this conference
is principally focused on health care and
value-based arrangements, we don’t wanna lose sight,
certainly in our organization, of the ultimate goal, which
is healthy communities and improving the lives of people in those communities. And it’s with that in mind, that as we’ve thought
about value-based care, clearly we wanna improve outcomes and we wanna reduce cost, and we recognize that to do that in the
context of health care, we have to change our delivery model and that includes not just the care that we provide to the patients who are coming into our clinics and into our hospital, but it also means providing care beyond those walls, in homes, and communities,
in ways that we haven’t done in the past. The great value of the arrangements that Patrick has talked about, like Blue Premier and others that we want to consummate with other payers is that it aligns incentives
to allow us to, in fact, promote health, and prevent
some of those visits to our emergency rooms and to the clinics that are unnecessary and
unnecessary readmissions. And with this in mind, we
have organized our activities through a Population
Health Management office, which allows us, in fact, to identify the workforce needs that we are requiring in order to expand our
care delivery model, as well as the priorities
around redesigning the care that we are currently providing so that we eliminate waste, importantly make our
care even more efficient and patient-centered. And through that office,
we are also looking at ways that we can play a role in
just educating the population even more broadly,
particularly the patients. So we think of our work through the Population
Health Management office is really principally focusing on the population of individuals that we’re caring for. Those that are patients, but those that might be under our charge through some value-based care and/or population-based care arrangement. But we see that as one big circle. Another big circle in population for us is the population of people
in our community on campus. And in that regard, to
complement what we’ve done to our Population Health
Management office, we’ve launched an endeavor
that we called Healthy Duke, and in here we have major
programs in five thematic areas, food and nutrition, motion
and physical activity, culture and environment,
and related to that, some of you saw, about six months ago we announced that Duke
University, campus-wide, was going to be smoke-free, that was one of the first recommendations to come forth as a result
of that initiative. Another area is the mental,
emotional well-being. And the fifth one is
fulfillment and purpose, recognizing that health,
as we think of it, in terms of physical and even emotional, is not the end for many, there’s
always a question of why, and what’s that larger aspiration. And so through these vehicles at Duke, we are seeking to fulfill
our broader mission of improving health in communities, and the community in this
case is Duke University, broadly, that community. And then the third population
that we’re focused on in terms of building a healthy community has to do with the
communities where we serve, and that starts with Durham for us, although we have a major
presence in Raleigh and we have similar activities there, and in some other
counties around the state, particularly through our relationship with Duke LifePoint. But in that regard, I
think, I was not here, but someone may have mentioned that we have helped, along with
county and city government, spearhead the Healthy
Durham 2020 movement, and in a similar way, we are focused on those underlying determinants of health that go beyond just health care. And in that regard, we are focused on nurturing those multi-sector and multi-stake holder partnerships that are required to really get at those key social, economic, environmental, non-health care determinants of health. In the context of this conference, though, I would underscore that we are committed to value-based care. We think that it’s overdue, and so we wanna be out front with other leaders in the state, ensuring that we realize
the promise in this moment. – [Mark] Thank you. (audience applauding) Thanks Gene, and Wesley,
it’ll go to you next. I know UNC Health System also has a big, and it’s been around for
awhile, a big commitment to moving in this direction
of population heath for example, and Medicare,
so-called next generation, kind of advanced ACO model already. Obviously a lot of opportunities for you all as well. – Yes, so first I’d like to thank Duke and Gene, the Margolis Center, just for the opportunity to
participate with you today, and to Mark, your leadership
in bringing us together to constantly in the
forefront of what we’re doing, talk about this, it’s a big deal, so thank you for that opportunity. As Mark alluded to in my introduction, I’m relatively new to the
job, not even a month yet. (audience laughs) And if you’ll notice, they are talking off of their phone, I
have my reams of things that I would like to talk about, just because of my newness. So thank you for being patient with me in that process. The mission, though, that
I hope that you remember from UNC Health Care System is to promote the health and well-being of
the people of North Carolina, that’s our commitment. It’s been our longstanding commitment. It continues through
the health care changes to be our commitment to the
people of North Carolina. I hope that we’re part of, we
are part of the leadership, and the change of value-based care that we wanna go there. The systems of transactional
fee-for-service have been in place a long
time and it’s hard to change, but we wanna be a leader
along with the others here. Many others throughout the state, and go in a different direction, because I personally
feel it’s a better way to provide health, to promote
the health and well-being of the people of North Carolina, the direction that we’re going. We’re fortunate as a state to have both public and private leaders that wanna go in the same direction for how we take care of people, how we work with people
to promote their health. That allows the health care systems to set up the systems within themselves to go to the same place. And so it’s an opportunity
for each of us in the state to go in a direction that’s
really unprecedented, as Mark has alluded to,
throughout the country. Our commitment in this is to
improve the patient experience to make it more affordable,
work with the payers, work with the physicians and
other health care providers, to do it in a way that
we can make those changes as easily and as quickly as we can. As Mark alluded to, we’ve
had a commitment in this area for a significant period of time. We have a partnership with CMS, and a next generation ACO. We have a partnership with
Cigna that’s been ongoing. The recent announcement with Blue Premier, with others that are on the panel, we think are really important because it’s the right
way to do health care. Our culture, our system is set
up to go in this direction. I think of the many bumps
that will be coming, the difficulties, as how
quickly will we get there, and how as a system, and
try to set up the systems within us that will help us
get there as fast as we can, but at the same time if
we get there too quickly, financially it’s difficult for all of us. If we don’t get there soon enough, it’s not the right thing for the patients. So there are lots of challenges
that I think all of us have and that’s obviously part of the reason we’re talking about it. What I hope that you’ll remember out of the few minutes that
I have to speak with you about UNC Health Care
is, one, our commitment to value-based care, it’s really there, it’s part of our mission
to promote the health and well-being of the
people of North Carolina. That in that mission, the second thing is that we really do want
to work with the patients, and families, and communities,
to improve their experience around all the issues related to health. Many of them are social determinants, as Patrick alluded to,
but we can play our part, and we’re committed to try to do that. And then the uniqueness
of the opportunity for us in taking care of the
people of North Carolina that are public and private partners, other health care system and partners, we all wanna go to the same place, and that’s truly unique
across the country, and I’m thankful that I’ve
stepped into this role at an opportune time like this. So, again, Mark, thank you for this time.
– Wesley, thank you. (audience applauding) And, Mike, I really
appreciate your coming over to Durham today, for this meeting. As you know, our center at Duke-Margolis works with a number of people at Vidant on some very hard health care issues, dealing with serious illnesses, and with people who often
have very limited means, or in neighborhoods with limited access or areas with limited access to care. Really glad to have you with us, and looking forward to your perspective. – Thank you, I really
appreciate the opportunity and I’m humbled and honored
to be with the participants and I’ve really enjoyed
the conversation today, and think there are a lot of common themes and the importance of really
a collaborative approach to dealing with what I
describe as chronic problems. And as an internist and an intensivist, I think sometimes we have the affliction of acute recognition of chronic problems and we think that quick solutions
will solve these issues. And I’m gonna represent, I could represent a number of perspectives,
but I really wanna represent those of the providers, the physicians, nurses and professionals that
serve Eastern North Carolina, one of the most difficult
health care markets in the United States. And I wanna start by
thanking our providers and their mission, because
we have been on a transition and transformation, frankly for many years at Vidant Health with our relationship with the Brody School of Medicine as explicitly producing professionals that deal with health disparities and with underserved markets in improving the health and well-being of Eastern North Carolina,
which is our mission. And it’s in our heritage. And we’ve made significant progress, on meaningful outcomes,
really unbelievable, considering the issues. But I think that much of
the conversation today and what we talk about inside
the academic organization and across Eastern North Carolina, our 29 counties, is the need
to accelerate and transform. Because we are at the
risk, at all of the risk of our communities, the health outcomes, the financial risk, and I always say if anybody that goes to
Eastern North Carolina thinks that there’s room at
the top of the price curve to push prices up, they
haven’t visited Bertie County or Duplin, North Carolina. So we really understand that risk, and have an intense and
intimate partnership with our communities. And geography does matter,
your zip code does matter. And there are real social, economic, health disparities issues that are related to the way the geography is. And we have structural racism issues that we have to overcome. And geography matters, and the
population densities matter. And sometimes people talk
about rural environments, but a mountainous region
is vastly different than a flat region with rivers, and people on islands. And so these things are structural issues that affect the way we serve our region. I just wanna reiterate what we’ve heard, which is our commitment and the commitment to transform, and the payer alignment and alignment of the financial incentives is imperative for that
acceleration that I mentioned. But transformation is not
for the faint of heart, I say that all the time,
in our organization. Change management has been my career, and it’s not just the providers that are undergoing a transformation. Our major payers have
to have new processes and new systems to measure and
to reward those measurements. And we have to also align with that as the provider community,
and transformation in rural hospitals is unique and hard for a lot of structural reasons. And I want to reiterate the importance of remembering the uninsured, because whenever you talk
about rural environments you have to consider the fact that the hospitals in
the rural environments are the only participants
in the value chain that are federally and morally obligated to take care of everybody
that shows up to the door, none of the payers, and no one else. And we take that as a
very serious mandate. The other important thing is time. We all need time to transform. You don’t transform overnight. I could go through many, many things about our transformation and talk about the structural issues that affect rural environments, but I think that I’ll just end by saying that we’re committed to that. We have multiple investments. We’re showing improvement in outcomes, but the other thing that I
would just remind us all, that it requires extreme
and intense collaboration, a deep respect for the local environments, the important of survival
for our physicians, nurses, and other providers that are in very lonely
situations in remote areas. Payer alignment with Medicaid expansion, I’m very excited about the
alignments that we’ve heard, but not all of the major
payers in North Carolina are on the same journey. And we can’t forget
that we have to educate the future workforce to provide care in these transformed environments. We’re highly committed to that, and we need more primary care physician in rural markets, that is
one of the major things we do know will improve the outcomes for those citizens. – [Mark] Thank you. (audience applauding) I’m gonna make one comment,
and I have a follow-up question for each of you, just to
let you think about that while I’m making the comment. It’s along the lines of
what keeps you up at night. About all of this, and what do you think would be the most important thing that this group in a
further collaborative effort could do to help with that worry. The comment that I wanna make is that, you know I had that
privilege over the years of being involved in a lot
of health care reform efforts nationally around the country. I have never seen anything like this, what we’ve seen today,
starting with Secretary Cohen, from the state, their commitment. Blue Cross, and as we mentioned
in that health affairs article that we wrote yesterday, other commercial payers in the state, you all mentioned Cigna, United, others that are taking very similar steps in a commitment to changing payment. And then so many of the
health system leaders, the ones we heard from this morning with medical society and elsewhere, primary care, all committed
to make change together. And for you all up here on the stage, this is not just words. You all have signed on the dotted lines. You are changing your business model, even though I think it’s
probably fair to say, all the details have
not yet been worked out on how that’s gonna be achieved. So it does seem like we’re
at a unique time here to build on some foundations
for success in North Carolina. But we’ve also heard, very eloquently, from our speakers this morning and many participating in the event, about some meaningful
challenges along the way, challenges that you all brought up too, like alignment of different efforts around measuring how
we’re making progress, around buying health, as Mandy Cohen said, and around sharing data. Other types of data support,
the stretched capacities of health care providers
in many parts of the state. The expectation that
there is gonna be a shift to more reliance on community resources and addressing the drivers
of health, and health costs, and those systems aren’t fully set up yet. Changes in expectations for
not just health care providers and health plans and
payers, but also people around the state. We heard from some of our business leaders about steps that they’re trying to take to change expectations
among their employees and the people who they touch, about really focusing on
health, not sick care. So that’s a lot to change, it really is, as people have said this
morning, culture change. If you could just pick one. I know there are a number
to choose from on that list, you may have some more of your own. What thing does keep you up at night that we should be focusing
on as we try to overcome the challenges along the way in this shift towards value-based care and better health, and
much more sustainable health care costs. And maybe let’s go down the line, Patrick, starting with you.
– I’ll go first. So, I’ll be honest, nothing
keeps me up at night, I fall asleep in about two seconds, (audience laughs)
which annoys my wife. But if it did, it is, this was the same
at Cincinnati CMS and here, it’s that I guarantee you right now there’s somebody that Blue
Cross is responsible for that’s not getting the care they need. And then I’ll give you a subpoint. It’s the affordability issue. I interact, as I’m sure others do. A farming family the other day, uninsured, just can’t afford unsubsidized insurance, and realizes the catastrophic consequences that could have on them. And a subset of affordability issue is the drug price issue,
which we haven’t talked to, but I think as a nation we need innovation and new drugs that help people. We also need a payment
system based on value, in my opinion, that allows access to it’s drugs.
(audience applauding) – [Mark] Gene. – Well, Mark, I, too, might be up at night if I weren’t on drugs. (audience laughs)
(panel laughs) – [Man] Will you share? (audience laughs)
(panel laughs) – No, most seriously. The thing that worries me, first of all, I am a CEO of a company, a multi-billion dollar company and it’s a company with
multiple constituencies. The first one is our patients. We consider patients and their families, their loved ones, as our
principle constituency. And so when I’m worried, I’m worrying about those miscues during the day, ’cause I hear about them. We now have a tally that
tells me on an ongoing basis how many harms we have had, by day, and how many we haven’t had for certain categories of outcomes within X number of days. So I run through that at night. The second constituent for me is that we’re an academic health system, and so at the same time
that we’re transforming our health care delivery system, we have to be attuned to the impact that that has on our academic enterprise, and that means our educational programs. It also means our investigatory programs and our ability to innovate. And in that regard, I’m often worrying about the fact that I don’t think that we are innovating at
the pace that we should, given the talent, and the resources, and the opportunities we have. And so I worry about
that missed opportunity. And then the third constituency for us, I go back to it, is our
community, more broadly. ‘Cause at the end of the
day, even with no miscues, and with a successful academic mission, we will continue to judge ourselves on a degree to which we
actually improved health in the community and improved lives. – [Mark] Thank you, Wesley? – So, like Patrick, I read my book and fall asleep at night. Unlike Gene, I’m not on drugs. (audience laughs)
(panel laughs) So I think the two things
in that proverbial, what would wake me up at night, one is that related to the patient, and two is related to
the physicians and nurses and other health care providers. For the patients that,
one, like Patrick said, they’re not getting
the care they need now, and how their expectations
for the care they get, or the care they don’t get, needs to, and we can help them change over time, and that we miss people in that change. So it’s a big cultural change,
not just for all of us, but just for people that receive care. Where to go when you’re sick,
who to call when you’re sick, if you have to drive 75 miles for an emergency department visit in Eastern North Carolina,
that’s really hard. So how can we do that
better, so that my concern about that patient and just
helping them in that change. And then the second, for
all of us that play a part in trying to provide that health, then how do we do that with
that group of individuals to help them get the younger generation. For the most part it’s been
trained interprofessionally. They’ve trained with the
nurses, and pharmacists, and others to some degree, much
more than my generation did. But all of us, how do we get there, how do we make these cultural changes? Because the reason we all
go into the profession is to help take care of people, to make them feel better,
to help them get well, to keep them from becoming ill. This is a better way to do it, but this wasn’t how I was trained. So how to get me in doing
that to a different place, so really those two things, the patient, and then the people that provide that. How do we help them change? How do we pull down the obstacles to help them change so that
we’re doing the right thing? – [Mark] Thank you, and Carmen? – Well the thing that keeps
me up, still, at night is the survivability of
the public safety net. As Secretary, I was responsible
for not only Medicaid, but Child Welfare, Social
Services, Public Health. And I have this conversation with myself, if we’re gonna start
running all this activity through health systems, we’re
already starving to death these other social service
agencies and workers. I mean you talk to a child welfare worker, the caseload that she has, compared to what we’re
envisioning a case manager in this new, new, new system, and the pay that this new case manager is gonna get, we are gonna continue to
starve the social service and the public safety net. So that’s, and since we
are all acknowledging that this is a long haul
transformation to value, where hopefully those
people will be sharing part of the value savings, the continual starving of these important social safety nets really
does keep me up awake. I mean if you just look
at, Medicare came out with data to show that if seniors, isolated seniors mostly,
but if they are provided an in-home meal, it
reduces their presentation at the emergency room by 33%. But what are our public
policymakers doing? They’re cutting Meals on Wheels. We’ve got, we know, and I know Mike knows this wonderful program in Eastern Carolina with Reverend Joyner, he’s doing gardening with 100 at-risk kids in his community. They wanna have a school garden so that they can provide
lunches for their peers, and sometimes they say,
I don’t want vegetables, I mean these kids are really,
but there are regulations in the FDA that prevent
that kind of a thing. And so, these efforts at this base level and the social support safety net, we really have to pay attention to that in this wonderful transformation, that I want each and every
one of these gentleman to be just as vocal at
supporting the public safety net. (audience applauding) – Really good. If you don’t have it,
if you’ve never heard of the, it looks like Conetoe,
but Conetoe, North Carolina, Reverend Joyner’s work, that we support with helping what we consider
the three important things in promoting the health and
wellness of our communities, which is promoting STEM education, economic opportunity,
and healthy behaviors. It’s an unbelievable
story and we’re so proud of the work they do. – [Carmen] And you even
do gardening for them. – Yeah we do, we do, we do gardening, and we create actually revenue streams so they can have college
funds for the kids, so it’s really one of many,
many exciting things like that. The things that keep me up, is really probably getting pulled away from those kind of things
and coming on panels like this exactly (laughs) No, I think, I think that
I pretty much said it when I started. I think it’s surviving transformation and payer activities,
whether it’s new Telehealth, new screening processes,
new management processes by payer that lead to
further fragmentation in the provider communities. Because I think, and because
I think that in environments, you know this isn’t an issue
in our 950-bed hospital where we have a lot of resources, but in a lot of our environments, it’s very difficult because
they just aren’t the resources. And so I think that fragmentation and surviving transformation with people that are attuned to
those local environments, because the rural
environments have low volumes of essential services. We have three hospitals
that have, on average, one birth a day, that if we weren’t there, a mother in labor in those communities would have to drive over an hour in labor. And we don’t make money on that service, I can assure you of that,
and we live in a state with one of the highest infant mortality and maternal mortality
rates in the country. We have contracting markets, but I always remind people
that they still live there, so I worry about them,
they keep me up a lot. The people that are left
in the second largest rural community in the
country, 3.2 million people. And in a lot of those environments, they are already resource
constrained and low cost with a dearth of resources such as food, transportation, roads, ferries, and the last mile. So for Telehealth, and
our home health services, which are built on Telecare management and Tele-Home Health,
the biggest impediment in some of our communities is actually connecting to the home because of lack of broadband. So those kind of things really keep me up. I could go on. Capital intensive environments, and physician, and nurses,
and other shortages in those environments. We are at a crisis in rural America as the CEO of Blue Cross
Blue Shield of Texas, the largest rural
community in the country, said, “Rural America needs a moonshot”, and if we try to transform and don’t do it with deep understanding
of 3.2 million people in North Carolina, we’re
gonna leave ’em behind. – [Mark] Thank you. (audience applauding) Well done. Mike, I am surprised you sleep at all. (panel laughs) And we will definitely be judicious in pulling you away for a panel. So thank you for being here.
– Well, it may be my last. – Yeah, and you grabbed my phone. (panel laughs) In all seriousness, I do wanna
open this up to questions in just a minute, but
maybe one quick line, row of comments on this. Secretary Cohen talked this morning about the importance of goals. One of hers, besides keeping her job for the next couple of years, was around getting to some outcomes that could be tracked for the health of the North Carolina population, total cost of care, getting that down. You all, and our other panelists, had a similar emphasis, on look, we gotta focus on things that matter, but we can’t have too long of a list for this effort to really align and share efforts, but something that’ll hopefully bring
this whole process along. What would you put at the top, or near the top of that list of goals that we ought to be tracking
for progress along the way? From several of your comments, it sounds like, Patrick, sounds
like you’re already there. A goal related to nutrition
access in the state, access to healthy meals,
Carmen emphasized that as well. Just maybe a very brief comment about what ought to be on the goal list that we do track going forward and why. And then I would like to
hear from all of you here. So please feel free to make
your way to the microphone. – Do you wanna go down again?
– Sure. – All right, so I’ll be brief. I do think a small set
of outcome measures, and I would do both
health outcome measures which would be some of
the drivers of health and also some health
care outcome measures. And we are doing that, I
know, we all are doing that. I do think total cost of care matters. I’ll put in an intermediate
outcome measure there on total cost of care. I do think we are measuring,
and I know the state as well, measuring the percent of our payments in these partnership models, these alternative payment models that are true full partnerships. And we’ve said publicly we
think we can get to over 50% within the next 12 months. And that, we believe, will
drive total cost of care lower, and quality up. And then last, I would
put experience measures, whether it’s traditional
patient experience measures. I think, or the next generation
of patient reported outcomes and patient experience measures, I think the experience
in the health system is suboptimal often, and
I do think experience matters to patients. – Ready Mark, okay.
– Yes, please. – Well I certainly agree with Patrick about those particular measures. Again, though, I’m gonna enlarge the way I’m thinking
about value based care, and I don’t think we
achieve our ultimate goal unless we, across the state, more effectively engage
patients and their families, and consumers of health care. And that, too often, is
missing from my dialogue and from our meetings,
and we’ve not, to my mind, made measurable progress. And there are ways that we can measure just the progress that we will make over the next few years in
terms of engaging individuals, and in engaging communities. I was in a meeting
yesterday with the founder of something that’s called the
Healthy U.S. Collaborative. How many of you’ve heard of it? And it struck me, we have a Healthy Duke, We have a Healthy Durham,
and we have a Healthy U.S. There is no movement or campaign around a Healthy North Carolina. There are pieces of it, maybe there is. – [Woman] There is. – Okay, yeah, because I went on, okay. I think it’s remarkable that most people probably haven’t heard about it, but to the degree that we
are already collaborating, I’m talking about all the partners in the health care sector,
and broadening that, along with the other sectors, I’m talking about other businesses, and certainly government,
and certainly faith leaders, and education leaders, and just an array of community-based organization. I would wanna see one of the metrics be somehow moving the conversation across the state and
deepening it at an individual and community level around
a Healthy North Carolina. (audience applauding) – So, Mark, actually I’d like
to partly answer your question and I’ll come to it in just a minute. But in reflecting about
what we’re talking about, we continue to use the
words value-based care, population management, and it seems, if we’re talking about
patients and families, it seems so impersonal. And when we say value-based
care to a family, they have no idea what
we’re talking about. When we say population
management, like they did, it’s not like a person
we’re taking care of. And so some way, as we come
together as organizations, in the state, public and private, that we change the conversation, ’cause really what we’re talking about is healthy-based care, not value-based. Value’s like financial, what’s the value, it seems like, we talk about value ’cause it’s valuable to us
to do it more affordable. And that what we really wanna do to help people take
better care of themselves and promote a healthy life
is healthy-based care. So some way, if we can
change that discussion, the nomenclature of it, in under healthy, so what does healthy mean? Track that, it’s a patient experience, it’s accessibility, that I
don’t have to drive 75 miles to the emergency department, or I know where the Urgent Care is, rather than go to the
emergency department. Things like that, under
healthy, are better, and will get us there rather than how many hospitalizations,
or if I go back in 30 days, or whatever it might be. So that’s what I’d hope we’d
chase the dialogue around, is to track the right things. – I like that instance (speaking faintly). – I’m gonna take a little
bit of a different take on an outcome I’d like to see, and it goes with my
comments about inclusion of lived experience
people in decision-making. And what I wanna talk about is governance. Legacy governance bodies
of most commercial MCOs and health systems, and
big provider networks have people who are on the
boards who are primarily skilled in fiduciary responsibilities,
’cause that’s basically what their responsibilities have been. In this new world of relational
value-based payments, I believe very strongly that these boards need to be expanded. In the behavioral health, at
least in our public system, that the one wonderful
thing about way back when, when we were doing the
first mental health reform was the establishment
of the Consumer Family Advisory Councils, the CFACs, and every single LME is required to have at least three CFACs members representing the different
groups of mental health, IDD, and SUD, on their boards, and believe me, it makes
it more of a generative governance type of model than
a strictly fiduciary model. So all these people here have boards, and I’m sure each one of them is gonna say that they have really good representation on their boards of
lived experience people. But I would like to see the department have some kind of measure of having that sector of our population
being in the decision-making on governance issues. – I’ll be extremely brief. I would just echo Gene’s comments. From our perspective, it’s
community-based measures, so I find it a travesty that
in most of our communities, the hospitals and health care providers are the largest employers. We should not be proud of that. And so economic opportunity,
education outcomes, and health outcomes, I won’t get into how you can measure that, we
could go on and on about that, but as an epidemiologist, and
as a health care operator, I would say to my comments earlier, that whatever measures we
use, there’s parsimony, because there’s huge
burden in the delivery, and the National Academy of Medicine and others have shown the
extreme cost and burden that we have to bear to
actually measure performance. – All right, thank you all. I’d like to get to as many comments and questions as possible. So start over here, remember,
just tell us who you are, when you ask your question
or make a comment. – [Jacqueline] Is This On? There we go. Good afternoon, my name
is Jacqueline Nikpour, and I am a nurse and a PhD student, and a health policy researcher in the Duke School of Nursing. First of all, I wanna thank you very much for a great and very informative panel. And so my question, as I listened
to you guys talking today and listened to speakers
throughout the day, talking about transforming primary care, and what we need to do
to get patients access, I think about some of
the other provider groups that may be underutilized. So for example, advance practice
nurses being one of them. And I’ve been listening to you talk and I think about the physician shortage. I wonder, what else is it that we can do so that in areas where there
may not be a physician, we can get the patients the
access to the care that we need because oftentimes we have in place very restrictive policies
that limit these groups of providers from practicing
to the top of their license. And the people that suffer
there are the patients, when they can’t, especially in rural North Carolina communities, access the care that they need. So my question for you
is, how can we utilize, and it’s not just advance practice nurses, so, often I know that the sort of thought is that the team,
there’s a team-based care modality in place, the
the leader of that team is the physician. But, for example, one
of my closest colleagues worked at an eating disorder facility, and the leader of that team was the behavioral therapist. You know where I used to work, in a pediatric diabetes unit in a clinic, the leaders were the diabetes educators and the nutritionists. So in these markets where
there may not be physicians, how else can we use these
other provider groups so that patients can get access
to the care that they need? – Mike, do you wanna take that one? (audience applauding) – I have, I totally agree. We have countless advanced, the shortage I’ve already mentioned and the need for access is critical, and having, opening the rules
around getting different types of practitioners engaged,
we have 21 practices that we’ve transformed in the patients in our medical homes,
but I hear your call, which I totally agree with. I’m not a policymaker,
I run health systems and lead transformation. And so I think that,
frankly, I’ll just be frank, my perspective is that we
tend to be very parochial. We talked a lot about the
need for collaboration in the different sections
in the value chain for value-based care. I think that the physicians
and other practitioners need to also open
themselves up to expanding, or not being so restrictive and parochial around what they feel is their domain area based on probably parochial interests. – [Mark] It can be very
important for the goals that you just described (speaking faintly) – Can I just? – I need be, get again
a little controversial, but you brought up the whole
issue of scope of practice. And if you haven’t been through
a scope of practice fight, in a legislature, or
having to deal with it as the Secretary, you don’t
know how vicious it is. And so, I agree that we have to deal with having everybody work at the top of their profession. But often the professions
are their own worst enemy. And so if you all could get it together and cross this cultural divide, it would be a lot easier
to change those laws and really do scope of practice in a very rational and
producing well-being for the people of North Carolina. – [Man] Good for you Carmen. (audience applauding) – I like that.
– A lot of nodding on the panel. – [Pam] Okay, I don’t know if this is on. Can you all hear me, okay, perfect. My name is Pam Silverman, and I am a professor
in the Gillings School of Global Public Health, and
previously I was the president of the North Carolina
Institute of Medicine. So in response to the question about is North Carolina doing something, we’ve had 2010 goals,
we’ve had 2020 goals, and the North Carolina
Institute of Medicine right now is in the midst
of developing the 2030 goals and objectives, so there is
something at the state level, just to answer that question. That’s not my question though. My question really goes to Patrick, because I’ve been in this field for now over 30 years. My background is working on
behalf of low income people, trying to get access to care. And during that time period, the whole, we’ve moved towards this
high-deductible health plans because we believe that there
should be skin in the game, and that’s well and
good for people like me who can afford the deductibles. But it’s not very helpful for the people who are the working poor,
or the working middle class who can’t afford those, to
get even into the system, so the whole discussion we’ve had today about value-based care
is based on the fact that somebody gets into the system. And if you have a thousand,
now it’s not even $1,000, it’s $6,000 deductible, people aren’t getting into the system. So have you been thinking about ways in which you can address that, so we can get everybody into the system so that they can get the benefits of this value-based purchasing that we’ve been talking
about all day today? – Yeah, it’s a great,
great question and point. (audience applauding) We are looking at this directly, so it sounds like you know this. There’s pretty good evidence on high deductible health
plans, that people actually, they both skimp on high value care, they skimp on low value
care, but also a lot on very high value care. So I would argue you need, so
therefore that’s a problem, and leads to worse outcomes,
less access, et cetera. So we’re actually looking at
all of our benefit designs with value-based insurance
design principles, where sometimes we are in control and we can lower copays,
deductibles, et cetera. Sometimes employers drive this decision, but we’re trying to educate
them on the potential impacts of these decisions. You know, as we enter the Medicaid market, we’re thinking about this a lot in terms of the benefit
design for that population that will maximize access
to high value services, and we don’t think that’s
a high deductible solution, that’s actually a maximize access solution to those high value services. So we’re thinking about it pretty deeply. – And aligning the value-based benefits with the payment changes
we’ve been talking about. Over here? – [Ryan] Hi, Ryan
Blackledge with Cone Health. Another question for Dr. Conway. As we look at this new
world of providers taking on just doing more, and I think
during your opening comments you mentioned care management. We also talked about things
like prior authorization, going away or having different rules. I have to imagine that that can generate some operational savings for Blue Cross. When those are generated,
what are your thoughts on what those might be, and
then how do you determine how that gets reallocated
back to providers, patients, payers, or elsewhere? Actually not payers, but the
employers paying for the plan? – Yeah, so let me, let me
do, briefly, our economics and then care management. So, yeah, we’re about 10
billion, 85% of our costs are medical costs, about
12% is administrative costs. Any administrative costs we lower, which we took out about 100
million in costs last year, we returned to our customers. So employers, individuals,
people that buy insurance. Prior auth in the care
management is a great example, and I would say we’re in
the beginning of this, so I don’t wanna, but with
Cone, with UNC, with Duke, we are having discussions
around how much savings on both sides could we have if we lower this friction in the system. So, admin, coders, prior auth, et cetera on the health system
side, I think big savings. And for us, as well, big
savings administratively. Now you do wanna do it in
a way that you agree to, and you’ve worked out. Actually, one of the
systems, interestingly, to bring it back to drugs,
we were talking about, do you want us to turn off
prior auth on high cost drugs? And they said, no thank you, keep that on, which is sorta telling
that there is some concern about how well could they
address the high cost drug issue without some sort of prior auth. But I think we should have
those conversations deeply and I think there’s real
savings on the provider’s side and the payer’s side. – Just to follow up on drugs, since you brought that up before. – Sorry.
– You are also trying, this is kind of a leading question, but you are also trying to
change the payment approach there to be more about maybe subscriptions, or more on a population basis
rather than a volume basis. – Yeah, so, two things. One, we own a pharmacy
benefit manager called Prime. We are in deep discussions
about what should the drug sorta industry
look like long term? Two, and you know this, we
are likely gonna come out with some RFPs. One will probably be in
the hepatitis C arena. But we say we want a competition
and we’re gonna pay X, but you’re gonna treat
every single person we find with hepatitis C. We’ll pick one of you and
you’ll treat everyone. So a true population-based
payment model on drugs. And I just think we have to
evolve our payment models in the drug arena. – Did you have a comment?
– No. – Okay, over here? – [Tricia] Hi, my name’s Tricia Gartland, and I’m a market access consultant. And perfect timing for my question, ’cause it’s actually about drug prices. So you mentioned value-based
payment for drugs and I think, if you look at,
even with the ACO research that’s gone on for high
cost areas such as oncology, ACOs actually haven’t really saved money in terms of drug costs
and even costs of care for those really expensive areas. And I think that’s in part
because the incentives for the different stakeholders
aren’t necessarily aligned when you look at total cost
of care being the driver for how you make decisions in
those really high cost areas, especially with all the
gene therapies coming, that will be curative,
but maybe the payers won’t see the patient
for their total life, and so they’re not gonna be
getting the result of that. How do you guys envision
us tackling that problem of the different incentives,
and how we measure value? – You know, this is, I mentioned
at the outset this morning that we weren’t gonna solve
all the problems today but we were gonna get into more depth. It think this, in all seriousness, this is one that probably deserves, from the comments in the people here today and from all of you up front,
some more serious look. It’s gonna be hard to be very successful in this population health
effort if the drug payments are not more aligned with value, too. So that’s a preface for a
longer effort on this topic, but a few of you have any
quick comments for right now? Sounds like agreement. (audience laughs) And we have about a minute or two left. Maybe if I could ask you
all both to kinda quickly ask the question and we’ll
try to get answers to? – [Lyneka] Very good, so
really quick, Lyneka Judkins, CEO of Forward Solutions,
where my company now focuses on making sure the community
providers are not left behind in managed care. Three months ago, though, I
was the executive director of Liberty Health Care, where
we do independent assessments on Medicaid beneficiaries
for personal care services. And unfortunately, what I
saw, about 30% of the time, is what stood between a
Medicaid beneficiary getting, a Medicaid beneficiary and
access to the services they need, personal care services, was the physician. They just didn’t understand
personal care services, they didn’t know how the
program that the state offered, and it had to be initiated
by a physician’s signature. And to try to get that
signature from a physician was very difficult. I think they saw it more of
an administrative burden, which they have a lot on them. As we go into managed
care, you’re talking about value, purchasing,
outcomes, healthy outcomes. How are we gonna bridge that gap so that at the end of the day, the patient is everyone’s responsibility, and community services doesn’t
fall just on case managers, or social services, but the physicians are just as accountable and
invested in that patient and becoming knowledgeable
of the resources that are out there and
making sure their patients get what they need, whether
it’s inside the health system or more community resources? – And maybe the other question
too, just to get that out. – [Man] Just to quickly
maybe ask a question, but the goal in care transformation, and it seems that we’ve
heard it again and again throughout the sessions today, is the alignment among
payers with providers, to work to achieve better patient outcomes as we create value to care
and to health systems. And then, the state health plan decides to take on a different way
of trying to reduce cost to its members. That’s not aligned with what we have heard and what we’ve been building toward in the discussions we’ve had here today. And I would like to
have the panel’s opinion on how they see the
impact to the reductions, close to $400 million,
and the way it impacts rural health care especially,
has a meaningful impact, what we can provide care, in Eastern North Carolina especially. I would like to have you all’s opinion and see if you could comment. – I say both of those are great comments, and I think on the first, about community service integration, I think you heard from
Secretary Cohen today that what you just described,
I think was exactly what she would like to see
happen out of these efforts, out of the 360 program, and as she said, building kind of an
accountable killer network on the community health side
that’s very much aligned with the traditional medical providers as kind of accountable
approach for all of it that focused on getting the
right services to people. On the question about the state treasurer, I don’t know if anybody wants
to comment on that quickly? I guess I would say that while
we’ve got a lot of alignment in North Carolina, boy,
health care is big, and complicated, and there’s
a lot of money at stake, and we need to keep working
together to do it right. I know not everybody
here has had discussions with the state treasurer,
and is thinking about how to move all of these
concerns about cost and access together,
but we’re not there yet. – I think everybody knows my opinion. (audience laughs) I initiated the clap on
Medicaid expansion this morning when the secretary talked about it, and I’d like to ask the audience, do we think that state
treasurer is moving us in the right direction
with taking $400 million out of doctors and hospitals
across North Carolina? So I think it’s not our question. And what do you all think? – Well, (chuckles) all right,
so another topic to discuss. – Thanks, thanks for the support. – Thank you, Mike, thank you Mike. – Can I touch on the first one? – Why don’t you touch on it.
– Just on the community one. ‘Cause with Secretary
Cohen we had screening and closing care gaps for communities should be as easy for a clinician
as ordering amoxicillin. You have to have a system that
the care team understands, there’s a reliable data system
and you can close those gaps. And so I think, fundamentally,
as we go into Medicaid managed care, and I’m sure
the Secretary did talk about this morning, it’s building
that community-based system that addresses drivers of health, and it’s embedded in
the system just as much as writing a prescription
or anything else we do in health care is. – Well, this has been a great discussion about the goals of health
care transformation in North Carolina, really about people, and this, as you were
just saying, Patrick, integrated approach to promoting health. It is really impressive to see the degree of commitment here. Obviously, there are still
a number of very important problems ahead to deal with. I wanna thank you all for laying
out those problems clearly, stating them boldly, and while we haven’t solved all of them yet, it’s
efforts like this that matter and I’d say what really matters is I really appreciate
the heart that all of you, as North Carolina health
leaders, are putting into the transformation. We’re very much looking
forward to next steps on this, potentially transformational, but also very difficult journey. Thank you all very much.
– Thank you. (audience applauding) – Thanks Mark. – [Man] I’ve been watching
you do this for years, it’s a great attitude. – Mike, always good to
see you, stay in touch. – Patrick, till next time. – [Man] You push, (speaking faintly). – [Man] Even while I’m doing this. (audience chattering) – All right, I would like
to again note, no breaks. We have our next panel, our final panel for this conference, coming up right now, on reactions and next steps for reform. I’d like to start by
introducing the moderator for this panel, Dr. Dev Sangvai. As you heard earlier, Duke
has a Population Health Management office, Dev
is the leader of that, and so is at the center of a lot of the population health
efforts, not just here at Duke, but also a leader in
efforts around the state, working with physicians
and other health care provider groups to transform care, and as well, he is a
teacher and faculty member in the Duke-Margolis Center. He’s gonna be joined by
a set of other leaders in healthcare reform,
including Betsey Tilson, who oversees a lot of the programs that Mandy Cohen was
talking about this morning, Tim Reeder, leader of the
North Carolina Medical Society, and just as another
sign that this is a true statewide effort, with UNC and Duke working closely together, Bill Roper, from the University of
North Carolina system. Dev, I’ll turn it over to you, thank you. – Good, so we had a lot of
questions in the last session, and this is primarily gonna be Q and A. So for those of you who wanna
stand up at a microphone and ask questions, you’ll get your chance. We’re not gonna do opening statements, we’re gonna go straight into questions. And I know it’s late, it’s the last thing, I’m glad to see everyone
stayed, but I promise you, we’ve saved the best for last. (audience applauding) And I just realized, I just realized, I said saving the best for last, and my boss was on the last panel. (audience laughs) I better, this is close to best for last, something like that, right? So we wanted to really
kinda get the perspective at the end of the day. We’ve heard a lot, we
heard from the Secretary, we heard from the employer community, we heard from health
systems, payers, and others, and we heard things like buying health, social determines the health, looking to the business
community, data liquidity, and so forth, and we wanted
to really ask individuals who are at the ground level, really thinking about
this day in and day out, from the perspective of the
community they represent, how would you synthesize,
and how would you think about the conversation we had today? And I know for some
panelists you may have been in and out today, so
thinking at a higher level, from the perspective of your organization, what does reform mean? And so maybe we’ll start with Dr. Tilson. If you wouldn’t mind, just
doing a quick introduction of who you are and what you do, and then tell us a little bit about what the concept of reform,
and some of the things we talked about today mean
to you and your organization. – Yeah, I’m very happy to be here. I’m Betsey Tilson, I serve as
your State Health Director, and the Chief Medical Officer for North Carolina Department
of Health and Human Services. I am a primary care
physician, primary pediatrics and preventative medicine,
still practicing primary care in the trenches, so really making sure the policies that we’re
putting into place, I can actually do when I’m
in my clinic seeing patients, so try to keep true to that. And I think from the DHHS perspective, we really are looking across the state, and really trying to think
about how do we improve the health of all of
our North Carolinians, and more so, how do we provide
that opportunity for health for all of the North Carolinians. And so thinking about the
themes that came up today and thinking about how we’re
thinking about our work, I was trying to bucket, some buckets, and one is to accelerate. There’s so much momentum right now, there is so much opportunity, so how do we accelerate that work,
how do we catalyze it, how do we resource it, how
do we organize it somewhat? Second is alignment, I think
we’ve heard a lot of talk about alignment, not just
between payer and doctor, or provider, but also across payers, and I think when you’re on the ground, when you are a physician, and you have lots of different payers, if
each payer has different rules, and different (grunts), it’s really hard to make that work on the ground. So how do we help foster alignment across our populations
or across our payers, and some of the things
we’re trying to put, a shared utility, shared tools, and I know NCCARE360 was mentioned, and so that’s an idea of
a shared infrastructure, a shared tool that we can put into place to align everybody. And then the third piece is
in how do we move to action? I think we’ve been having
these conversations forever, and how do we move to action? It doesn’t have to be perfect, right? But how do we at least start
moving some concrete actions, and so that’s what we’re really
trying to put into place. And then the last thing I will say is we do all this but we
also have to be mindful of we’re improving health for everybody and we have to make sure
that we’re not intentionally worsening disparities, and I think there’s some lessons
learned, especially when, in Medicare, when we moved
to value-based payment, that there has been some work looking at we might be worsening disparities as we move into value-based care and we have to really think
about what’s risk adjustment? That includes social risk,
but some lessons learned that we’re not unintentionally
worsening disparities by our goal to improve disparities. So that’s kinda what we think and how we’re organizing our work, and I’ll turn it over to somebody else. – [Dev] How about we
hear from Dr. Roper next. – Thank you sir. I just would begin by saying,
North Carolina has long had a reputation, justifiably
so, around the country, for being forward-looking and willing to do innovative things
in health and health care, perhaps the other states that come to mind in that regard are
Massachusetts, California, but people have long said North Carolina was at the forefront of things that have transformed our sector. And I think we have an
opportunity to do that again, right now, because we have a collection of institutions, whether universities, or the business community,
or state government, or nonprofits, we have
bright collegial leaders like the panel that you just saw before, Mark, and Mandy, and
Patrick, and many more. And we have a very fluid
policy environment, and you know the issues,
folks throughout today have talked about them, including
the growing focus on cost. But I think we are at a time when there’s a political
realignment in the state and across the nation. And I think it is going to cause changes that we haven’t even begun to think about, much less deal with. I served in two Republican
administrations, but I think it’s
undeniable that the country is shifting its focus to
be at least in the center, if not left of center, in the
most recent November election and the possibility of
that happening in 2020 is very real. And a thing that I frequently said over the last several
years to my colleagues at UNC Health Care is,
“Be glad it isn’t boring. “The next few years are
not gonna be boring folks.” And I think we, again, my major point, we have an opportunity in North Carolina to show the rest of the country how to do things in a
constructive collegial collaborative kind of a way. – So, as the President
of the Medical Society and a practicing emergency
medicine physician in Greenville, North Carolina,
I really want to thank you and the 12,000 members I
represent to be here today. And so emergency medicine
came up all times today, and it felt like I was
part of the evil empire. (audience laughs) And so, that’s okay. But I think that we in the Medical Society have been working really
hard to prepare our members for this transition to value-based. And educating them about the movement, and in the themes that we’ve heard today and the things that I jotted down were certainly that data is the key. And we’ve heard a lot about data, and how do we provide
data to the clinicians, and I think that Aaron
laid it out really well, that there’s really three questions. It’s the research question,
it’s the what works, the how do we provide
clinical decision support at the front lines, and how
do we know where the gaps are? I think those are three good things. I also have heard the theme
of that the work is local. So we talked about care management, or health system
transformation, or Dr. Smith talked about patients, they
want to get their care locally. They don’t wanna have to drive 70 miles, we know that that’s better care. I heard the theme that
health was an investment, that we should think about
not what’s the next year, but we ought to be thinking about health as an investment, like
we do about buildings, and it’s not something
we’re gonna do today that’s gonna pay off tomorrow. I think the one theme
that is missing in this, that I just wanted to speak to, ’cause it’s near and dear to our members, it’s the wellness of the providers, the physicians and the
nurses who are doing this. That we, it is, as Dr. Cohen mentioned, this work is hard, and
it is very difficult, challenging on the
providers that we’re doing. We know that physicians
nationally, about 50% of physicians are experiencing burnout. There’s 400 physicians
a day committing suicide in this country, twice
the national average. If you’re a female physician,
suicide rate’s five times the national average. That is a telling statistic. We won’t be able to
transform our health system if we don’t attend to the
needs of our providers. One study looked at ICU nurses, 25% of ’em were suffering PTSD from
the work that they do. And so all of these very important themes that we’ve talked about today,
they’re really important, we need to do the work, but
in the midst of all that work, we can’t forget about the
people who are delivering care. So I think that’s what
I wanted to make sure that we didn’t lose in
this big discussion today, because that’s what we as a society, we’re representing our members, and I think the other thing
that Dr. Smith mentioned, and I’ll stop talking,
was the underpinning of the healthcare system. What really the patients are looking for. It’s that relationship they
have with their physician. And no matter what we do,
if we design the system to make sure that the patient is aligned and with their physician,
that’s gonna be a good marker of physician outcome. I don’t know a good
statistic to measure that, but that, to me, would be a
good thing to come up with. – [Dev] Great, thank you. I only have two more prepared questions, so if there are questions
from the audience, please feel free to come
up to the microphones. In the last group we asked about what’s keeping individuals up at night, and we heard things like
affordability, safety, change management, insuring
the public safety net, access, and so forth. In many ways, they’re all
part of the same equation. As we think about that, and the diversity of representation we had, it really speaks to the need to collaborate. Can you talk a little bit about what it means to collaborate? ‘Cause we heard that health care is local. We heard that parochial
interests can sometimes dominate the landscape. What’s it gonna take for all of us to get on the same page and collaborate? You guys can collaborate and
pick somebody to go first. (audience laughs) – Rock, scissor, paper. – So you started with what
keeps you up at night, I know that’s not really a question, I’ll get to the collaboration question. But oh my gosh, there’s so
much that keeps me up at night, because I think we, as
Dr. Roper was saying, we really are on the cusp of being able to do something great. And I really think this is our opportunity to do that in North Carolina, right now. And so, and the scale and the scope of what we’re trying to do. I mean we have to be,
the big, the bee hive, the big hairy audacious
goal, we need to have that. And I think this is the state
to do it (exhales sharply). But the scale and the scope
of trying to do it, wow, but we’re only, we’ll
only be able to do it in collaboration, we’ll only be able to do it in partnership. We will waste so much energy fighting, and territory, and I wanna
build this (imitates garbling), that will not get us there. So we have to think about
where do we share resources, where do we collaborate,
and where do we compete? There’s definitely gonna be
lots of arenas to compete, but where does it make
sense for us to collaborate, where does it make sense us to compete, and I think that’ll be really important. And so I think, when I think about a lot of our healthy opportunities work, thinking about standardized
screening questions, thinking about a shared
technology platform, my big concern is, now
I’m just gonna have to try to get all of my health systems to agree to the same technology platform, and the same integration, and I’m, whoa, like that’s gonna be really hard. But instead of the idea of everybody building their own infrastructure, building their own solution,
siloed from everybody else, that, I think, will really not help us accelerate across the state. So I think it’s important to define, what do we share? What’s the shared resources that we’re all willing to co-invest? And then where do we need to compete? And I that’s important. ‘Cause it’s unrealistic to think we’ll collaborate on everything, right? But those lanes of where do we share, and where do we compete,
I think will be important. – [Dev] Great. – And I think that data sharing
is the underpinning of that. It was nice to see all the
health systems up here, all nice, but they do go and compete. And I think if we’re gonna think about how we deliver population health, or we’re talking about
the total cost of care, we have gotta share data across systems. Just if a patient’s at Duke getting care, and they go to UMC, and
they have to replicate, whoever owns that patient, whichever accountable care organization, that’s a waste of the system. And so, that data that
underpins what we do, we really have to break
down those barriers, and it’s not your data or my data, it’s really the patient’s
data, and we are just allowed to have access to it, but
we ought to break that down, and we need to somehow,
whether it’s a legislative fix, or whatever, to figure out how we can break down those barriers
and share that data that’s so important, so
that we are not duplicating and wasting resources. – So, to the first question,
what keeps me up at night, I would just say, I changed
jobs about a month ago. (audience laughs) And so I do have some things
that keep me up at night but they’re not related to this. If I can presume, though, to put myself back in the health care job, the thing that I think ought
to keep us all awake at night is the awakening that has
happened in the public’s mind, I guess, around two big issues. One is the demand, and it is that, the demand from the public that
we, the provider community, or insurers, or government, or whatever, pay much more than lip service attention to their wants, desires, focus, et cetera. And we all want to say things, like we want a patient-centered
health care system, that’s a nice glib expression, but I just urge us all,
and I can still put myself in that world, I urge
us all to really think, what would it be like if we set out to design health care in a way that was what will delight our customers, as opposed to how can we get by with the most convenient thing for us as the provider organization,
or whatever else? That’s a much different
way of looking at things. And the other thing that’s
happened, I believe, in a very big way, and
again people give talks about this these days, but I don’t think we’ve really paused long enough to understand it. And that is, the American
public have decided, broadly speaking, that health care is just too darned expensive. And I think we ignore that to our peril. We’ve been very good over time, and I used to work at a very big fancy academic healthcare
system, and we’re very good at saying what we do is unique,
and everybody oughta want it and everybody oughta pay for it. We need to do a much
more thorough going job at saying, how do we actually
lower the cost of health care, not as our former president used to say, bend the cost curve,
but how do we actually lower the cost of health care in America? I think unless we get serious about that, we got a major problem coming, because the public have
changed their mind, and we need to pay attention. – [Dev] Great, thank you. We have some questions, Dr. White? – [Heidi] I’m Heidi, Heidi White, I’m a geriatrician, which I
mentioned earlier, here at Duke, and I’ve heard a lot of
really good things today, but I don’t know if it’s part
of the culture of America, but I heard a lot of
things about individuals. How do we get individuals
to care about their health? And as a geriatrician, and there’s a lot of pediatricians in the room
too, I’ve discovered today. You know, a lot of individuals
are in family units. And it’s not just the worker
that is getting health care, or health care insurance
from their employer, it’s the family that is getting
that health care insurance. And when we think about
where care is provided, a lot of care is provided in the family. So my older adult patients are cared for by their family members, a
lot of other younger patients are cared for in family units. And how do we empower, we’ve
talked about communities in broad senses like cities,
and that kind of thing, but we haven’t talked
about how we can harness the value that we have
in our smaller units of family units, and
the care that’s provided within families, and the health knowledge, and the health education that really can move a whole family unit forward, and so just some thoughts on that today, would be helpful. – You gonna?
– I don’t have anything. – I just, I wanna do it. So I’m gonna put on my public health hat, and my pediatrician
hat, and my mother hat, which they all, as that. Absolutely, and I think
there’s the ecological model of health that folks
are familiar with that, that ecological model of health where there’s an individual, in a family, in a local community, in a state, in a national, in an international, and there are so many levers. And you really cannot influence health without thinking about
all of those levers. And you have to, so
that’s, when I think about, A, when I’m taking care of my, most of my patients are babies, right? So I’m not gonna say, hey, baby, you should care about your, you know. So, I always have to
think about the family and a lot of times I think
about the health of the mother. My priority is the health of the mother, because if my, if that
mother isn’t healthy, then that child isn’t healthy. I have to treat the
mother’s maternal depression if I really want that baby. So from a clinical standpoint, I always think about that
family from the family unit and then from a public health standpoint, again, that whole
ecological model of health is really, really important. And so when we think about what the pieces we’re trying to put into
place across the state, it has to be on all those, on
all those different levels. So, amen, absolutely,
and I think, when we, and I think there’s a lot of conversation about this isn’t really
health care transformation we’re trying to do, this
is health transformation, and that’s a very different thing, and there’s so many different levers, and so many things we need
to think about differently. – [Dev] Other thoughts? – I don’t have anything.
– Great, that was well said. – Amen, hallelujah, pass the plate. – That’s right, well I
will say one thing is that, sorry, is that I think we really need to pay more attention to
our aging population, right? Looking at our demographics,
especially in North Carolina. Whoo, we really, really,
really have to think about our aging population. And I think those natural caregivers, those family caregivers,
really, really important. We have to think about, we
have to think about well-being of our, of our, of our
healthcare providers. We also have to think about well-being of the caregivers, ’cause they really, and so that is a piece we
really need to think about, and I would say that we, as a department, we haven’t really gotten
there, ’cause we’ve been, and, but, but it’s really important, especially in North Carolina,
looking at our demographics. – [Bill] That’s a good point. – [Dev] Dr. Anderson? – [John] Hi, I’m John
Anderson, a practicing family physician and Chief Medical Officer of Duke Primary Care, an entity
in the Duke Health System that delivers a lot of
primary care in our area. And the thing that keeps me up at night is we talk a lot about value-based care, and moving from volume to value. The difficult time we have
is, so how are we gonna manage that transition? So I have to figure out
compensation systems that today are based on
relative value units, that are based on
productivity kind of systems, with the promise that once
we’ve made a transition to value-based care, I’ll have a pool of shared savings dollars to
cover my infrastructure cost, to build buildings with, to pay providers. But this getting from point A to point B is the challenging part. And I could say, well, we
look to the health system to support that investment. Well the health system’s
gotta pay for that as well. So the challenge that we face is this transitional period
as we go through this, and when we get there
I think we’ll be fine, but this getting from point A to point B is a real challenge, I think. – Tim, do you have any
thoughts on that, I know? – Yeah, if I could just
say you’ve articulated it quite well. That is the conundrum of
how do you today’s work while at the same time getting ready to do tomorrow’s work, and then manage through the transition. An analogy I’ve used
several times in the past is it’s rather like the
automobile industry in America, that knows that they’re gonna
have to make a whole lot more electric and hybrid cars in the future. They’re making money off
of big gas guzzling trucks right now, so how do you
get from one to the other? It’s a challenge, but we’ve gotta do it. – And I agree with that. We are in two worlds right now. And the other analogy I’ve heard is you’re standing on two
canoes and at one point you have to pick one foot up, and there’s no extra money in the system. And so I think going back
to that collaboration we talked about is we have
to quit being so siloed, and saying, what’s good
for me as the provider, or the health system, or the payer, we really need to break
down those barriers and say, we have got to
work more collaboratively together to figure out
how to create efficiencies in the system. I mean we’re spending
trillions of dollars. And so if we as a system can become two, or three, or 4% more efficient, which the system engineers
would say is not that hard work, there’s a lot of money out there, but we have got to become more efficient in how we provide and deliver care. – So we’ve had an automobile analogy, canoe, Betsy, you wanna close us out with another form of transportation? There’s the aircraft carrier. (panel laughs) There’s the A380, which one?
– Let me think. I’ll have to, I had some comments, I have to flip it into an analogy. No, so no is the answer. (audience laughs) I was trying to be clever, but no. So the other thing I think about is that we’re all gonna
be in different stages of capacity to make
this transition, right? So like some of our
bigger systems were made, they have a little bit more give, they’re gonna be able
to be more aggressive. If we think about, and
I know my lovely husband was here this morning
thinking about the needs of rural, independent physicians, right? They’re not gonna be able
to take risks day one. They’re gonna be in very different, so we’re gonna have to allow people, maybe it’s a highway, how about that? There’ll be a slow lane, and
then there’ll be a fast lane, that we’re gonna have to have people. – Perfect, it counts.
– Is that good. – It counts, it counts.
– That’s fine, thank you. That we’re gonna have to have people be able to be on a
different speed and move, all moving in the same direction
but at a different speed. ‘Cause we don’t wanna do harm
while we’re trying to move. And I think that it’s also gonna be, again sharing resources,
scaling the pieces that we can scale, so we’re
not just all reinventing ’cause that’s very inefficient. – The comment we heard
about case management, and imagine if you have
these five Medicaid care management in your same
office, if you’re a small primary care office.
– No you can’t do it. – You can’t do it, it
makes absolutely no sense. And so I am hopeful that
the wise folks in the state will recognize how we’re
gonna do care management. – Well that’s the advanced
medical home in Tier 3 and 4, that’s exactly what that is. – Until we get there, I think
that’s gonna be a challenge. – Yeah, that’s, yeah, yep, that’s that. – So I know we have a
couple more questions, but I wanna, I wanna ask, as you think about further
questions from the audience, maybe a frame of reference
we haven’t had yet, or I’d stepped out for a bit and maybe we had talked about this, is we have Dr. Roper, who arguably leads probably the best public health, or the public university
system in the world. Tim, I know that you.
– Thank you very much. – I can say that ’cause
Duke is private, you know? (audience applauding)
(panel laughs) – Tim, I know. – [Tim] We’d like to have a public option. (audience laughs) – Nice, and I know, Tim,
that the medical study is focused a lot on trying to create the next generation of
physician and even PA leader, and Betsy, the work that you’ve done through community care, and so forth, has been leadership
development and educating the next generation is a big
part of your personal focus. And it’s certainly a
big part of what we do in the Margolis Center,
is how do we really get the next generation
of health care researcher, health care policy expert,
provider, and so forth ready? What do we need to do to reform education, and I know that’s gonna
be like a half-day topic, but maybe you can say
it in a couple minutes, what do we need to do to
prepare the next generation for all of this stuff we’re talking about, ’cause it strikes me,
we continue to educate the next generation in
the context of change, and can we do that or do we
need to do something different? – Well, I think, so in my role at ECU, so I still work clinically, I
help with the Medical Society, and I teach. And one of the things
that we are going through a curricular transformation in
the medical school right now. And we are de-emphasizing
the basic sciences, we’re increasing our clinical exposure, but we’re also now
embarking on what we call the health system sciences,
the three-legged stool, now with medical education,
the basic sciences, the clinical sciences, and
the health system sciences. And one of the core components is that is quality improvement
in system change management and all those things
that we’re talking about. If we are gonna fix the system, we can’t continue to do
what we’ve done before. We have to transform. We have to educate our medical students, our residents, and ourselves
on how to figure out how to still do the work,
but then improve the work, and that’s one of the
principles that IHI taught us, is that you have two jobs every day, to do the work, and then improve the work. And so from the medical school at ECU, we’re embarking on that very much. From the Medical Society, the same way, we have our Keppel Leadership Institute, which has a couple
programs to help physicians who are out in practice, to say you can’t not transform your
practice, you’re gonna lose. And so teaching quality
improvement principles, the science of doing that
is an important component of the Medical Society,
and that leadership, to get ready for the future. – The broad thing I’d
say, and we could have a whole conference about
health professional education now and the future, but
the main thing I’d say is over the last few years
I’ve had the privilege of interacting with medical students, the public health
students, nursing students, pharmacy, dentistry,
et cetera, at Carolina, and I come away from every
one of those encounters extraordinarily impressed and very hopeful about the future. People in my generation
are grumbling all the time about how they don’t like what’s happened to the healthcare system, and they don’t advise people to go into medicine anymore, and that’s just a bunch of hogwash. At our university, both in Chapel Hill and the one at East Carolina,
I need to remind myself of my new job. (panel laughs) We have more applicants to
med school than ever before, higher quality applicants
than we have ever had before, and more commitment to public service and making the world a better place than ever before. And so I’m really excited
about the prospects for the future, and to harken back to one of the questioners a moment ago, I would just say, my wife
and I are both pediatricians, our now fourth year medical student son is interested in geriatrics,
and we’re delighted at that. He did it on his own, and we need it. So thank you. (panel laughs) – And I’d chime in that I’m thinking about some of the skills and competencies that our med students need, as
not what we traditionally got in med school, and so I
was just kinda jotting down some of the competencies. And I think some of this also, if we have our workforce trained in a
way that they really need it, I think that helps with burnout as well. So thinking about this
concept of team-based care. One of the questions from that prior panel was how do we get physicians to do more? We can’t get physicians to do more. We have to have that
concept of team-based care. And what’s the team, who’s deploying? And the physician can be
the head of that team, but really embrace that
concept of team-based care. I think we have to think about that. I think, again, we have to
think about whole person health, get away from that care to health, make it as easy to have
a prescription for food as it is amoxicillin, as Patrick had said. I think we have to think about
the life course perspective and I say that in terms
of thinking about trauma, the impact of trauma,
and trauma-informed care, which I think we miss. 25% of North Carolinians
have had significant trauma in their life. 41% of our adult Medicaid
patients, significant trauma. We are just, we don’t know
how to ask about that, we don’t know how to handle that, and we really start thinking
about trauma-informed care, I’d change that dynamic completely, and that’s, even missed amongst
our social work students, they don’t know it about,
we, we, we don’t talk about trauma enough. A prior comment about this,
we have to kinda get away from that individualistic behavior. Like you are, we have
to get away from that, or really understand what
drives health behavior. How do you change health behavior that it’s not all just
that individual choices, but understand the complexity
of health behavior, ’cause I think that can
be really frustrating. And then finally, I think
we have to be a lot better thinking about shared decision-making, thinking about motivational interviewing, thinking that the physician isn’t, actually, to be perfectly honest, the physician is never in charge. The patient is always in charge. And so thinking about that idea of what are those communication skills? What’s that shared
decision-making schools? How do we change that dynamic so that patient provider dynamic is so much more satisfying for everybody? And I think those skills, we
haven’t traditionally taught as much, and I think that’s
what’s coming to get us on the back end. It’s like, I know about your kidney, whatever, I don’t care, like what, what I, how do I help you think about
making the change in smoking. And so, those are the things that I think that we haven’t done a good job at, that we need to do better. – That was good. – We have a couple more questions, over this side of the room. – [Awilda] Hi, my name is Awilda, and my question is going
back to your comment on how we transition in the aging in making sure that
they don’t fall behind. But what about a long term care services and like those members that require that more in-depth assistance and the people with disability. How is the state envisioning
transitioning that population to managed care and ensuring
that their needs are being met and that those assessment that are done are people are really paying
attention and listening and not just filling out
and completing a checklist like someone here mentioned earlier. The population is so frail and it’s just one of the concerns that we’ve
been hearing a lot about, them falling behind and not
having the proper services while the transition take place. – Guess that’s me?
– Yep. – Yeah, so I think you’re right. We have, so we have our population and then we have a vulnerable population, then we have really a
vulnerable population, so we have to think, and then so, one way that we’re trying to address that. So as we go into Medicaid transformation, we’ll be launching our standard plans that are for our people
with a little bit less risk. But then we’re taking a lot more time to launch or tailored plans. And so the tailored plans, specifically, are one of the most
vulnerable populations. So those folks with severe
persistent mental illness, intellectual developmental disability. That’s a really important
population to get right. So we’re planning more around that. Let’s make sure, what are all
those specialized services? What’s the right care management? What’s the right assessment? Let’s make sure we do that right, same with our foster care,
I shouldn’t say that, our children in foster care, that’s a really important
population as well. So we are, we are delaying that because we really wanna, and
it’s not gonna be perfect, I’m gonna tell you right now, it it is not gonna be perfect there. But, those are really,
are, are, and I hate to even say vulnerable, because that’s, ’cause people have their own strength. But the populations we wanna
try and do as best as possible ’cause we know there’s
much more complexity there, and so we’re trying to be
really mindful of that. – [Dev] Question over here. – [Susan ] Hi, Ron, thank you so much. My name is Susan Harrell,
I’m a fellow member of the evil empire. I am an ER nurse, over here at Duke. – Whoo! – [Susan] I think what
the ER shows us is really just a lot of holes in
the healthcare system, and we get to see, we have the privilege of seeing a lot about what is working and what is not working. And so throughout the day I’ve
been meeting so many people from so many areas of
the health care world, and we are hearing
about a lot of problems. And we’re hearing about insurance, and about data, and all of these things, and I would hate for us to walk away without hearing about
something that you guys are really excited about. Whether it’s something on a policy lever. – You took my closing question. – Or a technology lever,
a piece of reform, or a piece of innovation that you feel has actually made a difference
in the past five years that you’re really seeing,
or something that you see coming down the pipeline that can get us revved up, thank you. – That’s great. – So, thanks for a good ER plug. So I do primary care emergency medicine, that’s what I’m gonna call myself. Didn’t go over. (audience laughs)
(panel laughs) Too soon, too late, I don’t know. – I got it. – So, what I’m, what gives
me enthusiasm and hope is a little bit what
Dr. Roper talked about. When I get to interact and
teach these medical students, they are not grumpy,
they’re not burned out about the future. They are looking at this
as, we have a chance to transform and do
something very different than what is there today. And when I talk to them,
and I still don’t feel like I’m that old, but
when I say the internet wasn’t invented when I
went to medical school, and they’re flabbergasted. They say, how could you do anything? I said, well, we.
– We read books. – We had a library, we had books. And so we had to know, we
had memorize those facts because we didn’t have access to facts. And so what gives me hope, and we had a quality symposium yesterday, where three of my students
won the best posters of the day for the work
that they are doing. One was improving turnaround
time for bilirubin, one was on HIV screening in
the emergency department, one was transforming how we do scheduling. That gives me hope that there
is some incredibly bright, smart people out there,
who are gonna create the healthcare system
for us in the future, so that’s what gives me hope. – If I could just take Dr. Reeder’s point, and enlarge a bit on my son. I mentioned earlier that he’s
interested in geriatrics. Actually, he’s interested
in emergency medicine with a focus on geriatric
emergency medicine. And when he was trying to
get into medical school, he worked for a year and
a half or so, two years, as a CNA in a hospital ED in our state. And as he was in that process, and coming to understand what happens in emergency departments,
one day he was home and talked to my wife and me, and he said, “Dad, I’ve discovered “that there are two kinds of doctors. “There are two kinds of physicians.” He said, “There’s one who gives orders “and tells other people what to do, “and there’s another that
brings people together “and creates a feeling of teamwork “and helps them perform together.” And he said, “If I’m able
to get into medical school, “that second group is
the one I wanna be like.” And I said, “Hey, that’s
an important realization, “and secondly, if you get an
interview at a medical school, “tell them that story.” (audience laughs)
(panel laughs) All of that is true,
but the point I’m making is he came to that on his own, and that’s just one more example of why I am optimistic about the future. – Yeah. – So I have three things. One is I’m really nerdy but
I’m really excited about it. So, the MLR, I’m excited about the MLR, which is really crazy, but this is the medical loss ratio, right? And so this is what plans have to, and Patrick was saying it,
what plans spend on people as opposed to what plans
spend on administration. And so one of the things,
we’re trying to do everything for a lot of populations, but also pulling as many levers as we can within Medicaid. So one of the things
that we were able to do in North Carolina is able
to define what counts in that numerator, the MLR. And you have medical
costs and then you have quality improvement costs. So with the state, we were able to define investment in food, investment in housing, investment transportation,
that’s quality improvement, that gets to count in the
numerator of your MLR, which has not been the
case in other states. So that really frees up our plans to really invest in health. So I’m so, it’s kind of
small, very concrete, but that is a huge lever that
I’m really excited about, our definition of the
numerator of the MLR. I know that’s, but, the second thing I’m really excited about is our
healthy opportunities pilots which are part of our 1115 waiver, and this is really a place
that we can accelerate and really think about how do we define, how do we deliver, how do
we pay for health services? This is that kind of
accountable care community that Mandy was talking about. This’ll be an unprecedented opportunity for us to really think
about health system changes and how we finance that, and
I’m really excited about that, and the way we’re setting it up is to meet very rigorous evaluations so we can all learn, not just in Medicaid, but across all our payers. How do you actually do this? What’s an augmentation science? How do you actually do
this, and pay for it, and think about those,
that true payment reform. I’m really excited about that. And the last thing I will say, is I’m also incredibly
excited about NCCARE360, which we haven’t really gotten into, because that is how we’re building these coordinated networks, that is how we’re gonna share data that
we haven’t shared before, that is that shared technology. And we were with WakeMed on Monday, and I will leave it on this. We were at WakeMed on Monday, and those of you who know Brian Klausner, who heads a lot of their
population health for WakeMed, he started the morning
by saying, “This will be “the most important thing
you ever do in your life.” That’s how he started the morning, so that was awesome. And at the end, we closed it,
and we were getting questions from the audience, and this
was an honest to goodness question from the audience, that said, “This is awesome, are you ever overwhelmed “at how awesome this is?” And I was like yeah! And we’ll just end on that. So I just think we really,
if we really embrace each other’s partnership, I just, I think we can do so much. – You know, one of the other things that I think of, brings
hope and optimisms, if you kinda replay the
entire event in your mind, we started by hearing from the Secretary of Health and Human
Services in the context of one of the biggest
decisions in health care in North Carolina. We heard from the business community how they wanna be a part of the solution. We had a panel where
three largely competing health systems sat side by side to talk about how we can help
healthcare in North Carolina. And we had physician leaders who bring a wealth of
experience, sharing ideas, and I think what gives me
a lot of hope and optimism is the fact is we actually
wanna solve this together. There isn’t this you solve
it, not my problem mentality that we see elsewhere. So while we have looked at North Carolina as everything from the Bellwether, the example, and so
forth, I think the fact that we have people here
on the cusp of the weekend sitting here having this dialogue really speaks to the fact that
we want to solve the problems for North Carolina. That’s really all the time
we have for this panel. I think, Mark, are you
closing out the event here? – [Mark] Oh yes, I’ve got words of wisdom. – There we go.
– That was great, thank you. (audience applauding) – It’s a great panel and
I’m just gonna keep you all a couple more minutes, but I do wanna say a couple of things before we finish today. The main thing is thank you. And that was gonna be the
only thing I was gonna say, but I’m gonna add one more. We started, as Dev just
said, with Secretary Cohen. We had participation
from state legislators. We had participation
from leaders in all walks of the health care system, and especially we had participation from all of you. People in academics, and
business, and the community, health care providers, payers, lots of different perspectives, and all coming together. And I just wanna echo
what you heard from Dev, it is great to see the
enthusiasm and optimism about the future mixed
with also the realism about what it’s gonna take to get there, and I think maybe most importantly, a commitment to hard
work, to make that happen. At Duke-Margolis, we’ve got a lot of staff who helped put this event together. Faculty contributed, but
I think what’s really gonna make a difference
in taking advantage of this opportunity is all of you. So I would like to just
do a round of applause for everybody who made
a difference here today, especially those of you joining us here, and also on the webcast, thank you. (audience applauding) So, as Secretary Cohen
started out the day, saying it’s time, it’s time, it’s time. Betsey Tilson just now, on
the cusp of doing something great here, from the
standpoint of our center at Duke-Margolis, we are
committed to being part of this effort, to doing our part in it. There are a number of
specific ideas and directions that came up today that
do present opportunities for further action together. I like the discussion about collaboration on the big topics, but we
still have some important roles for competition, and
innovation, and differentiation, and finding that the best way to get there among the areas where we
will be doing more work is supporting the development,
and implementation of the key data sharing and systems to make it easier to deliver
much more coordinated care, to work with. The business community,
as you heard this morning, wants to be a stronger
and more effective part of transformation, to help
with the areas of alignment, and measures, and in aspects of payment, to help make action easier. And certainly in the educational programs, our interdisciplinary
Margolis Scholars Programs, very much aligned with
the goals that you heard on the last panel. So none of this is gonna happen overnight, but I really believe, based
on the true commitment that I’ve seen from people
who are working with us, leading up to this event today, and most importantly going forward, that we can make it happen
right here in North Carolina. Thank you all very much for being a part of this journey with us. Thank you and have a good rest of the day. (audience applauding)

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