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The Agenda. The state and its largest private insurer are working together to transform how health care is delivered state-wide. Then both came to North Carolina, determined to put their ideas to the test in the real world.Keynote Speaker: Using Artificial Intelligence for Cyber Defense by Nicole Eagan
Combined, they cover well over 6 million people, more than half the state. Together, they made North Carolina arguably the most innovative state in the country when it comes to improving how health care is delivered and addressing the underlying social and economic drivers, like homelessness, of poor health and high costs. North Carolina is not the most obvious place for an outsized health care experiment. Democratic Gov. Roy Cooper intensely wants to change that and cover anotherlow-income people. The Republican state Legislature, just as intensely, does not. A physician and policymaker, Cohen held several high-level health jobs in the Obama administration and helped implement the Affordable Care Act.
But she also undertook broad efforts to tackle homelessness, hunger, lack of transportation, domestic violence and other socioeconomic drivers of poor health —sometimes by smartly leveraging a Medicaid dollar, sometimes by partnering with another state agency or community-based organization. In the Obama administration, Conway, also a physician, had led the Innovation Center, a laboratory for Medicare and Medicaid to test new ways of financing and delivering care.
Traditionally, health care payments were based on the quantity — not quality -- of care.
Now, the mantra would be value, not volume, improving health while restraining costs. But they were doing it in a uniquely broad, collaborative and fast-paced way, in a laboratory that spans the length and breadth of the state. Cohen and Conway described themselves as rowing in the same direction, in a national health care environment that often seems to have far more oars in the water than it does boats.
Other states were watching. Their ambitious, dovetailed initiatives were moving right along — and may well do so again soon. But twin blows landed this fall: A bitter state budget stalemate triggered partly by the expansion fight, delayed Medicaid reforms for at least a few months, jarring providers who were already anxious about the coming changes. Several health care experts who follow Blue Cross or who are directly partnering with them on innovation projects, say the health plan is moving at a steady pace despite the upheaval.
They had hired Conway in the first place because they were institutionally committed to bold change. That means they will have incentives to focus on prevention, early intervention and managing patients with multiple chronic conditions.Women show that 50 is only a number
For both Medicaid and private insurance, keeping people out of the hospital saves money. Tools ranged from expanding Meals on Wheels to setting up a food pantry at a health clinic. Blue Cross has dropped Obamacare individual market rates by nearly 10 percent over two years; Its Medicare Advantage rates, which affect many more people, plummeted by 30 percent in — and an average of 31 percent for One goal is for pilots to span rural and urban counties, sharing and spreading services and resources, including the ificant amount of data needed to make this all work.
Wake County includes Raleigh, where social services are bountiful, at least compared to other parts of the state. But she envisions a six-county pilot, two urban, four rural. Pearson runs a public clinic with an unusually robust set of services, offering everything from the bread and butter of public health immunization, STD testing and the liketo same day visits for acute flare-ups of chronic disease, to mental health treatment, to handing out recipe cards using healthy locally grown vegetables and pointing patients to food pantries where they can get them.
She deals on a daily, if not hourly, basis with housing, hunger, domestic violence. Transportation is particularly irksome. Her clinic is close to a hospital, an inpatient mental health program and an assortment of medical services built around an abandoned textile complex in Smithfield.
In a county that now haspeople, a mix of its rural roots and growing exurbia, there is not one iota of public transportation. By law, Medicare and Medicaid dollars can be used for patient transport only under narrow circumstances. Providers are nervous about all the changes in the pipeline, the new ability rules and capitated payments. But they also see opportunities.
Most of the kids and teens Goldsboro treats at its four offices across two counties in eastern Carolina are poor. Deeply rooted in his community, the senior physician and practice founder, David Tayloe, is a fifth-generation country doctor from a line that dates to the Civil War. The practice now has more than a dozen physicians, along with nurse practitioners, physician assistants, social workers, therapists, a lactation consultant and a Medicaid care coordinator for complex cases.
That reduces stress on working parents and diverts avoidable visits to the ER. But as he meets with a broad array of community groups, the potential hits home, he said in an interview in his clinic earlier this year. He worries particularly about the pervasiveness of mental illness, estimating that it now affects 1 in 5 young people in his area.
Not long ago, there were maybe 50 school-age children in families that lacked a permanent home. While the Medicaid pilots ramp up, the state is partnering with United Way and other nonprofits on a social welfare online platform called NCCARE where anyone — doctors, nurses, clergy, community workers, a hospice -- can turn to get help for someone, whether it be housing, financial assistance, job placement, protection from abuse.
By late summer, it was in more than 15 counties; it will roll out across all counties in the state by latepulling together dozens of agencies, public and private.
Too often, a social agency gives a person in need a list of phone s and sends them on their way. There is transparency and ability. I can see the progress.
I can follow all the way through. A proposal earlier this year by the state treasurer to lower health payments for public employees pegged to Medicare fees, though more generous met fierce resistance and was withdrawn. Early adopters — the kind of doctors, nurses and clinics that grant interviews and tell visitors about how excited they are about change — tend to be the ones who are already doing what they can to tackle social drivers and value-based care. The idea is to scale, learn, scale some more. Other insurers are moving toward value-based care too, but not all at the same pace, and not all with the same metrics and requirements.
Medicare, too, has its own set of rules, and that can still pull providers in multiple directions, noted Valerie Lewis, who studies payment reform at the University of North Carolina, Chapel Hill. The best health care providers will juggle competing demands; the worst will keep looking to game the system. Cooper may lose the governorship next year; that would mean Cohen would be out of her job.
The group practice has already embarked on all sorts of efforts to address social determinants and chronic conditions, ranging from asthma to long-term consequences of childhood trauma. When cutting-edge research labs get old, they face a new kind of challenge: Upkeep is expensive, and it's not sexy.
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