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tv   VA Gov. Ralph Northam Other State Officials on Medicaid  CSPAN  November 20, 2018 6:40pm-8:03pm EST

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up next, virginia democratic opener discusses medicaid expansion in the state had the recent america's health insurance plan conference. an additional 400,000 low- income adults would gain access to medicare coverage in virginia beginning january 1 of 2019. the state joins dirty to others and the district of columbia and expanding medicaid coverage under the informal care act. after the governor's remarks, healthcare officials from north
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carolina and virginia took part in a panel discussion looking at the challenges and benefits of their state medicaid program. this is about an hour 15 minutes. >> good morning everyone. i am not isles, on president and ceo and we are extremely honored today to have our next speaker, the current governor of virginia, governor ralph northam. when you take a moment to introduce him to you and we will get into a little bit a conversation in a bit. the governor is a 73rd governor of the commonwealth of virginia., northam has been an
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army doctor, a pediatric neurologist, a business owner, state senator and lieutenant governor. he is a native of virginia's eastern shore. governor northam was educated at the virginia military institute and eastern virginia medical center and served in the united states army, so thank you for your service. governor northam is committed to building a virginia that works better for everyone, no matter where they live. please join me in welcoming governor ralph northam. [ applause ] >> good morning. i looked at the schedule for you all, you all are getting up early in the morning, i am impressed with that. as a child neurologist, we like to get up and make our rounds early, so this is a good time of day. it is good seeing some friendly faces from virginia. i know you all are from all
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over the country and perhaps the world, so welcome to washington and if you get a chance, come on across the potomac river. it is not that far away. matt, thank you for your kind introduction and for the opportunity to be here and just to say a few words and maybe let you know where we are with medicaid expansion in virginia and how we got there. the first question though that i want to address and i am often asked is why would a pediatric neurologist get into politics and that is a question i look in the mirror every day and ask and i can't get an answer. back in 05-06, i was practicing child neurology in norfolk, virginia at children's hospital of the kings daughters and pam and i were raising our two children, one of which, he is
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30 now and he is a neurosurgeon down in chapel hill, north carolina. our daughter is in richmond, she is a web developer. it's a good thing that both her children are employed. back in 05-06, i had a lot of frustrations with healthcare. i felt like i was working a lot more hours and had a lot less to show for it at the end of the day and i was complaining to our chairman one day and he said one of you do something about it? the first bit of advice i would like to give you all this morning, if you choose to run for public office, it is probably a good idea to run the idea by your spouse, first. once we got past that hurdle, by the way we are still married, 33 years, so i ran for the senate in virginia, the state senate in 07, without really any political experience or background and we were successful in that campaign.
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i ran again in 11 for reelection and then in 2013 they were looking for someone on the ticket to run for lieutenant governor who had some rural background and also had some experience in healthcare so in a weak moment i said that i would do that. and we were successful, and so i wanted to tell you this very quickly experience wise in the senate, i really jumped in the deep end back in 08 and then a cane had traveled around and listen to a lot of virginians and they said they would really like to be able to go into a restaurant and not be exposed to secondhand smoke and he came to me and said as a pediatrician, you would be a good person to carry that piece of legislation so when the governor asked you to do something, you say yes, sir or yes, ma'am. without any experience and not really having any relationships of not knowing the system, i
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jumped in the deep end with a piece of legislation that you might imagine was very controversial in virginia, the tobacco industry essentially built virginia and if you talk about bringing people out of the woodwork when you come up with a plan like that, it did just that. what it did for me is i realized that it was important to work with both sides of the aisle. the piece of legislation passed in the senate in 08 and as we say in richmond, it caught a bit of a fever and when it got down to the house, they said that is too much government in our lives so they defeated it in the house. the next year though i reached out to people and talk to them about the ill effects of secondhand smoke and i think they realize that it was a good idea to ban smoking in restaurants so in 09 we were able to get it passed in the senate and the house and then it was signed by then governor
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kane. i've also done a lot of work as you might imagine as a child neurologist. i used to see a lot of children, student athletes with concussions, so we were able to work with both sides of the aisle and come up with a protocol of how we manage concussions in virginia, which brings us to being governor and medicaid expansion. we were eligible since january 2014 to expand medicaid in virginia and as part of the affordable care act and by the way i think there's some great things about the affordable care act like no more pre- existing conditions and being able to keep your children on the policy until they are 26. i realize i'm preaching to the choir that a lot of people really thought the affordable care act was a good idea, but when you talk to them about obama care, it was terrible. we got past that, but medicaid expansion as part of the affordable care act, we had the option in the commonwealth of virginia to expand coverage to up to 400,000 working and i
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like to underline the word working, of virginians who prior to that didn't have access to seeing a doctor or provider and what i tell people is that no person, no family should be one medical illness away from financial demise. i just thought that was immoral not to be able to go see a provider, because we are all going to have a day when we are not feeling well and we are sick and we need to get medical attention. the other part of the equation though that i really promoted in virginia was from a business perspective, and i was a cofounder of our business back in 96, we started children specialty group with about 35 pediatric subspecialists and we now have about 100 patrick subspecialists, so i know what it is like to start a business and grow a business. every day that we weren't expanding healthcare in virginia
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, we were just leaving it on the table, we were giving it to our surrounding states who we compete with over $5 million a day so we had forfeited over $10 billion a day. i used to go around and tell people as a business model, if you came to me and said it is a good idea to give your competitors over $5 million a day, i said as a neurologist, you ought to have your head examined. so i think that hit home with some people. the other thing that i was able to do, world virginia is, and i'm sure it's true in the country, is still hurting. we have never recovered from the recession. over a third of our hospitals in rural virginia were operating in the red. the opioid crisis was just alive and well. so i really reached out to legislators on the other side of the aisle and said we can
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help for a virginia and we can help your hospitals and help people be more productive and we can help them get jobs. >> we had republicans from rural virginia, and i think this is the right thing to do, and the other thing is there reality that we had an election in 2017 in the house of delegates, and we picked up 15 seats, and the makeup was 21 republicans and 49 democrats. then in the senate, there was 21 republicans and 19 democrats. people were more willing to sit down at the table and do what we needed to do. we were able to expand medicaid this year, and it put about 322 million more dollars in our budget, which we could use for
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education and transportation and mental health care. we was pleased to do that and where we are right now, we have a dual track, and we have the state plan amendments, and there are 13 of them and we applied for them, and i think the cat is out of the bag, but i am going back to richmond when i leave here, and we have been approved to move forward with that. we will start enrolling on november 1, and we will have people eligible for their health coverage on january 1 of 2019. i think that will be a good thing for virginia. then we had the other part of that dual practice, the 1115 wave your. we have -- waive your -- waive your -- waiver. it is not dependent on the state plan amendments are not dependent on the 1115 waiver. the last thing
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that i would tell you and i think we will probably talk about this a little bit is as we move forward with healthcare in general, and especially with medicaid, i look at healthcare as really having three pillars that supported. the first is quality and we have great quality i believe in this country. people come from all over the world to receive our healthcare. the second is access and we have improved access by expanding coverage. there is always room for improvement. but the third area which will take virginia and take this country to its knees if we don't wrap our arms around it is the cost issue. we need to sit down at the table and put the politics aside and say how can we address the cost of healthcare? a lot of things that we need as healthcare providers and administrators to work together, and the last thing i will say and i know we are going to talk about some other things and address some questions, but it would really
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be nice to get the politics as best we can out of healthcare. it has become a political football if you will, and it is not fsa brain surgery. but it is going to take people who are willing to sit down at the table and shut the door, get they are in the d out of it! r and dd -- r and letter d out of it. thanks for allowing me to be with you this morning and thanks for all you do will -- with healthcare. i want to make sure that everybody has access to affordable and quality care throughout this country and in our case virginia. thank you all and i look forward to your questions. thank you. [ applause ] >> thank you governor, that was a really great table setting for a conversation and you have touched on so many important issues around public health,
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rural providers, and opioid, and your experience as a pediatric neurologist. when you think about and congratulations on the medicaid expansion and getting that over the finish line, and when you think about the expansion, was there a tipping point in terms of being able to get that over the finish line? you talk a little bit about the changing political dynamic coming out of the 2017 election, the was there 1-2 things that stick out in your mind that you saw this is really a good possibility for it to happen? >> i think there was a couple of things matt, and one of them was the realization that the affordable care act was here to stay. that was an attempt to repeal that in congress and it didn't happen. it came close to happening, but he didn't happen, and i don't think there was any viable option on the table to replace it, which we was very worried
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about. i think that the folks on both sides of the aisle and virginia realized it was here to stay. the election of 2017, people, and i am not a big fan of poll, they are very concerned about their healthcare. legislators tend to listen to their voters and certainly when there was 15 seats that change in virginia, that brought people to the table. i think the other thing again from a business perspective as i mentioned, the amount of money that we was forfeiting to other states, and the fact that rural virginia is still not recovering and the hospitals are operating in the red. just a number that you can hang your hat on, in virginia plaster, we lost 1227 people in virginia to an opioid overdose. that is more than who will die on highways and gun related
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accidents. a lot of these things work together, and we had a good team. i think there are policy folks who work with people on both sides of the aisle, and one of the advantages i have had as governor is that i had been in richmond for about 10 years, and i served in the senate for six years as lieutenant governor , and in part of that job you preside over the senate. i had good relationships with people on both sides of the aisle. i like to promote the virginia way, in other words we can agree to disagree, but at the end of the day, let's do what is in the best interests of virginia. one last thing that i will say, we balance our budget every year in virginia, which is a good thing. in order to balance the budget and by expanding healthcare as i set about $322 million came into our coffers over the next two years. all of those things played in.
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>> we might be lacking a few things in washington maybe from that approach like balancing the budget and thinking about those things. you talked about the political football that politics, that the affordable care act sort of has created with a back and forth on both sides. also, the efforts around repeal and replace last year that was unsuccessful. do you think coming out of that debate there is a different view maybe did not -- maybe just out of the affordable care act and the role that medicaid plays in terms of being an important safety net and public program? maybe that did not exist? you! >> if you talk to most virginians and i suspect most people around this country, there is three priorities right now.
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the first is that people want a job they can support themselves and their families with. in order to have a job, you have to be healthy. you cannot work if you don't have good health. the second is that people want their children to have access to a world-class education. but the third and probably the most important is that people care about their healthcare. when people get sick and they have to make a decision whether or not they can see a provider, or pay for their bills or food or etc., that will get people's attention. i think just a concept and the advocacy for people when they need healthcare, having that option to go and see someone, that hits home with people. >> you talked about some of the public health challenges, and thank you for your work on getting the smoking ban enacted. i think all of us appreciate being able to go into places and have them be smoke-free right now. but there is so much other
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public health challenges and you touched on opioids for an a moment. issues like diabetes and rates of obesity and chronic conditions that are affecting a larger share of the population. how do you think that medicaid expansion and the role of medicaid in general in terms of addressing some of those public health challenges, which are also very personal health challenges as well for many people. >> a couple of points that i would make and one of them is that when people don't have access to healthcare, there is this crash and burn approach. their only access is to go to the emergency room when they get sick. that is very expensive number 1, and number 2, it is not the best place for preventive care. they are either in the emergency room or the icu if they are addicted to opioids. did they end up often in a jail or a vintage entry, which is very expensive. i think you touched on point that i like to really talk about, and that is when we address the cost issue.
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the resources, and if you look at the resources we spent for healthcare, a lot of them are going toward things we can prevent. things like type ii diabetes, cardiovascular disease, cancer center calls from various ages like cigarette smoking. the old saying that you hear a doctor say an ounce of prevention is worth a pound in cure. i think we need to shift our resources from things that are treated at the end of life to prevent it. just a quick point about end-of- life care. i have been the medical director of our pediatric hospice for about 20 years now. everybody should have advanced directives number 1, but i think if we message end-of-life care and talk about care and hospice as the quality of life issue, it will also become a financial issue. the last thing that i would say and i mentioned education when i said what is important to people.
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we are advocates for early childhood education, and there is a tremendous learning potential in our children before they ever get to kindergarten, and it does not, as children are very impressionable at that age and you can talk to them about nutrition and staying away from cigarettes and drugs and that type of thing. one of our goals in virginia in the next three years is to make sure that all of our children have access to early childhood education. >> it is ensuring that you mention that because at this conference, and really this entire week, these are people who represent medicaid health plans and other types of health plans that operate in the healthcare system, and the theme around the influence of social determinants of health whether or not it be access to healthy nutrition, education, where you live, a safe environment, how do you think that will evolve with medicaid and more broadly in the healthcare system and how the focus is changing?
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>> i think it will actually help the expansion of medicaid, and one of the areas and i don't know if you have mentioned it and i think you said this but it is affordable housing. when people are homeless and they don't have a roof over their head, they are very and healthy. another part of it is dental care as people need access to that as that is part of the overall health of the individual. i think as we move forward with the expansion, get people enrolled, help educate them to prevention and those types of things. i think overall it will help the quality of care and address the cost issue as well. >> in virginia you noted there is a diversity of providers, in our big urban areas in virginia and obviously some rural areas, and talk a little bit especially given your background and experience sort of the struggles of rural
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healthcare dividers and how you think that medicaid expansion and how we more broadly should think about rural healthcare providers in an effort to expand in those areas. >> it is a great question and number 1, i talked about jobs. for rural areas of the country, we need to bring jobs back so that people will be able to stay and live and raise their family. the other thing and the point that i make is that i talked earlier that about a third of our hospitals in rural virginia are operating in the red. how are you going to recruit a provider like myself or a nurse, they are not going to want to go work in a hospital that is getting ready to potentially close their doors. with the expansion of healthcare is to make our hospitals healthier, you are much better able to recruit individuals. we really need to use incentives
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to get the providers to go to rural virginia. a specialist in neurology, it is very difficult and scary sometimes to practice alone in a rural area where you don't have the support or radiological support or the lab support. i've seen a lot of people who have tried to practice in rural virginia, and it is very difficult. i think we need to incentivize people to go to those areas. the last two points that i would make is that we passed legislation this past year in virginia that would allow nurse practitioners to work independently after they have had a number of years working under the supervision of a physician. but i think to be able to take advantage of our nurse practitioners and physician assistants in rural virginia is important. >> that is a great point, and i
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know a lot of people here have been very supported of efforts like that because we need to be able to expand care into areas where it is hard to get. within the healthcare system there is other areas where we know there is significant shortages and different types of positions and care providers, particularly in the area of mental health. we know and you mentioned some of the tragic numbers around opioids in the state of virginia, and we know we had the deputy attorney general roger olson stein here yesterday talking about some of the department of justice efforts there. what is your view of the sort of mental health system and how do we think about enhancing the number and types of providers that we have to treat in the mental health issues? >> one other point that i would like to make as far as reaching out to rural virginia as there
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is a tremendous amount of potential and we are trying to ramp up training individuals who can't know how to use telehealth. as far as mental health, i am sure that virginia is not unique as it is a tremendous challenge, and one of the main challenges is reimbursement. with medicaid expansion, we are honestly going to need more providers, and that is something that needs to be addressed is how do we reimburse providers and how do we reimburse hospitals? we have in virginia what we call community service boards, and that is where individuals have access to mental health care, and we have a program that is addiction and recovery services. that is been a very successful program in dealing with individuals who have mental health and addiction problems. as part of expanding healthcare,
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we have been able to increase our reimbursement rates for individuals who are trained to recognize addiction and deal with addiction. again, a lot of what we can do is do we have the resources to do it? that is one of the reasons i would recommend that any state, with the affordable care act, take advantage of the expansion of medicaid, and don't be sending those dollars to other places when you can use them in your own state. >> you touched on the role of telehealth, and i know that has also been a theme throughout the week and ways that we can leverage technology. given your unique vantage point of a healthcare professional throughout your career, what is your view of technology whether it be extended to different types of digital healthcare programs, and applications and telehealth, and you like to put your hands on patients and what
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is happening with them physically. how do you see that this might evolve in our healthcare system? let's just talk about the reality and i will use myself. when i see a patient, honestly need to take a history and examined that patient. perhaps do some testing, and once we establish a diagnosis and a plan of care, there is a lot that can be done over the internet. probably 90% of it, if we just touch base with the patient every month and every week, and we depend on their needs and say how are you doing and how is your medicine, is it working as it should? they don't have to get in the car and worry about transportation, and so i think you can significantly cut costs, and also improve the quality, especially in rural virginia. i am a big fan and obviously if
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you need surgery or something, you will have to come in. a lot of the administration of healthcare can be done through telehealth. i am very excited about it. >> you have been very generous with your time, so one final question and you mentioned the three pillars around quality, access, and cost. out of those three if you could wave a magic wand and say that we need to stop and address this one first or in which priority, do you have any perspective on where we really need to focus? we need to do all of them, but we really need to get to this one first. >> i am going to be political, and i think all three of them are important. as you think about it, if you increase access, and you increase quality, then you drive your cost up. it is hard to balance all three, but i really think the most important pillar is the
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cost issue, and again, there is a lot of things that we can do to emphasize the preventive care and talk about end-of-life care that we can do to address that issue. i think that it is important for our patients and our consumers to have some skin in the game. they need to have responsibility with the cause, and probably most of -- costs, and probably most importantly and we are getting short on time, but providers like myself have to be responsible for the cost. people always ask what is the most expensive piece of technology that we have in healthcare? people say it must be the mri or a cat scan. the most expensive is this pen right here. we need to teach our's students and residents and providers that we are responsible for the cost of healthcare. we are also by the way when we talk about the opioid crisis, and i have heard so many people
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who have gone down the path of addiction and say how did it start, and they said you started with a prescription from a provider like me. we need to take responsibility as providers for a lot of these issues as we are all in it together. >> that is a great closing message and please join me in thanking the governor. [ applause ] >> i would like to ask you to remain in your seat as we transition to the next session. i would like to invite our good friend matt salo to the stage and our next panel. thank you very much.
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>> good morning everybody. it is a pleasure to be here and it is always a pleasure and thank you matt and governor as it is always a pleasure to follow a governor on stage. a little bit intimidating. i spent 12 years with the national governors association and you think i would get used to it, but i still am not. for the next session what we are going to do is to do a deep dive into medicaid transformation. i am matt salo and the executive director of medicaid directors and we represent all the state and territorial medicaid directors. i have a little bit of a view from the national level as to what is going on. we are thrilled to have two state experts here with us. i will turn to them in just a second. first, we have jay ludlam, who
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is the assistant secretary for medicare eat! medicaid transformation. we also have ellen montz who is the chief health economist ended direction of health in virginia. as you will see, they have some similarities and some differences in terms of how they are approaching medicaid transformation. what i think that i would like to do is frame this discussion a little bit, and perhaps even offer up a thesis to see if these two experts can't confirm or deny essentially what i am proposing. my perspective again, trying to think through what are the similarities and what are the common themes and threads of the 56 states and territories, it is a little bit like herding
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cats as they are very different in many perspectives. new york, texas, california, and alaska are all very different. as i think about it, to me, there is a couple of really important commonalities and very important thread that do bind us all together. one of them is that truly the core objective of medicaid in the medicaid agency is very much the same in every state. it is to provide the best possible healthcare to the people that we serve while also being responsible stewarts of the taxpayer dollar. in doing so, in a way that is politically and culturally relevant in the state that you are in in the capital from which decisions are made.
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that leads to different decisions being made, but at the core, this common goal of improved healthcare quality, monitoring and maintaining sustainable costs within a political reality, it leads to an enormous amount of practicality and pragmatism across all of the states that i have found just incredibly refreshing and encouraging throughout my career. the second thing, and this is the thesis that i want to explore here today, is what else of the common themes and threads across state medicaid agencies, and to me and to an oversimplify it a little bit, it really is a journey. it is a journey that the states are taking, some are at different parts on this journey, and some are taking slightly different roads to get
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to the destination, but the journey ultimately is medicaid is recognizing that for too long in this country, the healthcare system whether it be medicaid, medicare, or even commercial payers, the health insurance has been for too long a passive bill payer. what health insurance and medicaid needs to be is an active purchaser of better health. so the journey is how are we transforming the healthcare system? medicaid doesn't exist in a silo. is very much a part of the healthcare system, which is 18% of the nation's economy. so how are medicaid agencies
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taking the historical reliance on fee-for-service, unmanaged fee-for-service, and going on this journey toward a future where patient care is holistic, patient centered, better coordinated and better manage, and ultimately, those types of delivery system changes and the breaking down of the silo is and goes hand-in-hand with fundamental changes as to how we pay for things in this country and how we pay the provider that the governor just talked about. how do we pay plans, nursing homes and hospitals? that has to change too. that is my 30,000 foot thesis
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and i hope i am not proven to wrong! too wrong by our two guest. we are going to have a little bit of a conversation in a moment about what is next. with that, jay ludlam, north carolina. >> thank you and good morning everybody. sticking with it journey theme, north carolina, we have approximately 10 million citizens in north carolina, and 2.1 million of them are in medicaid. that is a little over 20% of our total population within the state. many of you will know that north carolina, and we have a system, we have a model, which handles our behavioral health issues for a vast majority of our medicaid beneficiaries. that we have a local model that handles the physical health. our journey is about going
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backwards a little bit to go forward. we are in the process right now of procuring a whole person centered model managed-care so that we are putting under one umbrella, the behavioral health, the physical health, and the pharmacy services that are necessary to serve our medicaid beneficiaries. in large part, our vision is through this one whole person centered care, we are going to be able to drive accountability and be able to maintain sustainable cost in the program, and i'm not going say most important, but importantly, we will also be able to have a full view of the quality outcomes that our provider and health plans will be delivering. so our process started about
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three years ago with legislature passing the authorize legislation for managed-care, and we have been in the process of developing that. ashley, this friday tomorrow, our bids are due for managed- care, health plans, for what we are calling standard plans. i am a little surprised to see anybody here. you should all be home writing your responses, but perhaps you have already printed them and they are on their way. it is absolutely a journey and a journey that for north carolina, it will last at least another four years after we go live and faith in additional populations, and more complex populations. >> thank you. so, ellen montz, virginia is in a slightly different position on this journey.
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talk to us about where you are now and perhaps what kind of lessons you have for north goal line or other states? >> good morning everyone and nice to see you. when matt asked me to speak about medicaid expansion in virginia, i was a little overwhelmed, but i said that is just because we call it medicaid. we don't see this letting up anytime soon, particularly as two very large accomplishments come together in our state, to solidify the future foundation of our program. the first of what you heard the governor speak a little bit about which is beginning on january 1, virginia will expand medicaid to adults up to 130% of the federal poverty level. this will be the single largest medicaid increase in our history. by expanding this eligibility for medicaid, we will generate further savings for our taxpayers and create jobs in our community. by reducing the number of uninsured people, we will strengthen the hospital an hour -- every aspect of our healthcare system.
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most important, we will have a system in virginia that helps make sure the people in virginia and their families don't fall through coverage cracks. our second accomplishment coming to a head at the same time is that we are very near- complete in our transition of all of our medicaid population, and almost all of our medicaid services to managed-care. we are at the telly and of the upcoming journey by jay ludlam. 95% of the full medicaid members are enrolled in managed care and as i mentioned with very few exceptions, almost all of our services will be provided to managed-care, by the end of this year. the journey of virginia, as matt calls it, and every state has one, the journey to managed- care happened in two spurs. it began 20 years ago when we began to cover our services for our pregnant women and our children.
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then, we waited a while and over the past five years, we have completed this near full transition to managed-care, specifically beginning in 2014, we transitioned all of our waiver population into our court medicare manage program, which included our services for long-term services and support. in april 2017, we set up our addiction recovery and treatment service program in our managed-care program. finally, to be completed by the end of this year, we transitioned all of our community mental health services into managed-care. it is at this convergence of our your completed managed-care transformation and the expansion of medicaid eligibility, that we look to the future for our medicaid transformation. i think we will get in as we discussed kind of the lessons learned and what we see going
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from here, but for us, very much as a state, we have had a lot of experience in moving population and services into our managed-care, and what we haven't had and we have had some initial experiences with, and we will take that moving forward is starting with the base of we will perform our medicaid transformation within managed-care, it is just about how you do it. that is a big contact specific and i think we will get into that. >> great. a couple of thoughts, and i know i want to end off toward the next half hour and invite questions from the audience. a few things to kind of throw out there. one thing that i have noticed is i have gone around and talk,
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especially to a lot of state legislators across the country, and talking about medicaid and managed-care, and this journey that many states are owned, is that you sometimes get an interesting perspective and people say that is privatization. that can mean different things on different sides of the aisle, and can mean the state is just absolving itself of any responsibility in turning over the care of honorable people to some other unknown entity. other people sort of say, that is great, move it over there so we can eliminate that function of state government. to me though, the managed-care and medicaid is very much a public and private partnership. it means that in a lot of different ways and i would love to explore with the two of you is that a fair depiction of
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what medicaid managed care is, and if so, what is it mean for you and what does it look like? >> so in my experience, legislation, or legislate doors, will often -- legislatures will asked me if we moved to managed- care, how many state staff are you going to cut? if they are doing your work, you don't have to have staff necessarily to be in the medicaid program and to oversee it. in fact, i would argue in fact that you need a different kind of staff, and you need a very sophisticated staff who will oversee and monitor the quality of the services being provided by a managed-care entity. we emphasize to our internal team that we as the state
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remain responsible and accountable for the state plan services that we have agreed to provide a partnership with cms, and it is important for us that we do not advocate that responsibility, and that we work closely with our managed- care companies in implementing in north carolina as we get ready to implement. i think also, that we are going through a competitive bid process, and the benefit of a process like this is that you are as a state selecting the most qualified partners that you possibly can. if you deem them qualified partners, you should work with them as partners. we are trying to embed in our staff a sense of mutual accountability and responsibility, but hopefully, we as a state are responsible for how a beneficiary and provider are treated in the
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field. we do expect also our managed- care organization will work closely with the beneficiaries and the provider to try and head off any issues, and if necessary, work with the state to resolve those. i do agree and a large bar, a private public partnership in that way. >> i would say certainly. we view this as a partnership. it is not an abdication of responsibility. we are the ultimate responsibility for the quality of care that our members receive. but i tend to think of this is more of a partnership that allows government, and in this case are medicaid agency and our plan, to do what they are best at, to get the best outcome for our members. for us, that is about aligning incentives, between our member
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outcome, and our plan. that is about how we set up and we as a medicaid agency, set up our plan for success. by setting the rules and regulations at the state at the contract level to rely on the plan to create that value for our members. so i think in virginia, we have had a lot of success doing that, particularly stemming back to 20 years ago when we began our transition to managed- care. we will continue to evaluate that success that we have had with our new transition into managed-care. i think what is particularly great about this private and public partnership that we have with our plan, is that it is a relatively agile partnership. we can make changes relatively quickly through our contract
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and through our partnership with one another, that may not otherwise be possible in a different scenario. we very much view it as a partnership, but with the i that we maintain as a medicaid agency ultimate responsibility for the care of our members. >> given that, and i don't want to put you on the spot jay ludlam, if i was to ask you what do our private partners need to know in order to be successful or need to do in order to be successful in medicaid managed care? what is your advice or what are the things you would say? >> it has to be done differently than in the past. i cannot answer that.
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we have spent the last probably two years, and we especially when wrap up with governor cooper, becoming governor last year, and secretary mandy:, we have worked -- secretary mandy, and we have worked hard to publish a series of policy papers and tried to articulate the vision that we felt was important for everyone to understand, and that was important for our beneficiaries and providers. but in a large part, our health plan and in fact, we published a provider experience paper, and we published a visionary experience paper, and we published a health plan experience paper. we have tried to articulate as much as possible what kind of partner we are looking for, and laying out expectations as much
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for our beneficiaries and providers about what kind of behavior and innovations we expect from the managed-care plan. this is something that we have been doing and having the conversation for well over a year now. so that when this when this came out, and you are clearly sitting here and relaxed with your response, but i think it is some that we have tried to articulate all along. survey so ellen, you guys -- >> so ellen, you have been asked about managed-care so long, and what are the qualities and traits of a highly successful managed-care approach will bring in virginia? >> i think it is just that. it is the management component. it is the kind of care coordination component of our
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managed-care plan. i think as we think about health insurance markets and we think about the individuals that reside in these markets, medicaid is a very large insurance market, in our state, and often times the largest one in any given state. the population and the services provided in the medicaid market are often the same as other markets in acute care. but they are also different than services provided in other health insurance markets when we think about our long-term services and support. we think about kind of the various populations within medicaid that have a continuum of care needs. i think a successful managed- care plan in the medicaid market is one that kind of recognizes, will recognize the differences
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and address specifically differences in the medicaid market, which i think is a very hot topic these days as medicaid grows and in particularly virginia. i do think it is that kind of specific focus on medicaid as a unique market. >> so one of the things i kind of want to delve into a little deeper, and this really gets at what ellen, you was talking about, the patient experience and the quality of care. you kind of see this topic woven throughout the agenda here, at this meeting and the agenda and a lot of different meetings. it is the focus, the relatively new focus, on the social and economical determinants of
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health. it is almost becoming a clichi, we'll talk about that, and it is easier to talk about than to actually do. we had an interesting conversation the panel yesterday where we were sort of questioning what is the role of medicaid either in terms of delivery or financing of the social determinants of health? where do you see north carolina and virginia going with focusing on these types of interventions, as who is going to provided and who is going to pay for? what is the future of it? >> there are a lot of different ways that a medicaid agency or a department of health and human services like in north carolina, like how they can drive the conversation around the social determinants of health, and i think yesterday cindy called on social
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influencers, but there is clearly something there. the way that we frame it in north carolina is that our responsibility is to buy health and not to buy healthcare. if that means paying for an emergency room visit, we will do that. if it means investing in a preventative care visit or a vaccination, we will do that. but if it means also making sure that somebody has three meals a day or has transportation to remove them from being isolated in their home, that is something that we will also do. it returns health to the individual and ultimately there is not only a societal benefit, but there is a good old- fashioned saying.
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i don't know if it has been fully measured, but the weight north carolina is trying to drive the social determinants conversation is that in our pending approval, our 1115 waiver, which i hope is approved any moment now, we have advanced the concept of four social determinant pilots to be integrated within the managed-care platform as it speaks to some of the flexibility that ellen mentioned earlier. managed-care provide us with an opportunity to embed within it the opportunity to investigate where, how, the social determinants can make an impact. we have approached cms in our 1115 waiver to inject up to $850 million over five years into social determinants of health, and the way we have
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embedded that in and care is that we as a department want all providers in north carolina assessing their patients for potential social determinant risks. are you hungry and you have transportation or are you a victim of violence? do you have housing issues? just to name a few. we have updated the pushing out across the state an assessment tool, but our provider struggled. i have identified that there are individuals who are hungry. what do i do about that now that i know? we are working on a resource platform at a department level that gives providers access integrated into their medical system. access to resources that will meet the needs of their patient in managed-care the weight we are working through this opportunity. we are embedding it within the care management model in
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managed-care. if the care manager determines that these are services that are needed, they will approach these pilot agencies, the social determinant product agencies, who will be required to develop a network of community-based organizations to fulfill their needs, and those care managers will dry that utilization and that opportunity for the beneficiary and the provider. similarly, we are also at the state working on developing a payment structure so that again, even this model is sustainable as well. of course we believe there will be a good return on investment and we want to develop mechanisms to assess that. we will call them rapid cycle assessments, and that is something that cms and north carolina are working toward
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defining more clearly. we are also working toward value-based purchasing toward social determinants. it would not be wise necessarily to start off with a fee-for-service model for social determinants. we are looking for ways to provide upside incentives and potentially downside risks in the future. the flexibility of managed-care in a medicaid environment integrated with the rest of our department of health and human services so that it is not only a medicaid thing, but it is something that all providers across north airline can take advantage of. >> honestly, i always want everything that you asked for from cms to be instantly and 100% approved. >> i appreciate that. >> my control over that is minimal, but would you say that your ability to really continue this path forward is contingent upon that waiver getting
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approved or is there other ways to do it? >> it does not, but it will be very helpful to have $850 million to inject into something that we think has a lot of utility and value. but no, as this resource platform is completely independent of medicaid in fact, the assessment tools that we are developing for providers and north carolina is completely independent. but these tools will also be embedded within our managed- care, and our expectations for the managed care organization, and we expect them to utilize their care management. we are trying to provide them with some flexible the in their care management model to be able to take advantage of whatever opportunity they are able to identify, independent of whether not these are approved or not. >> ellen, how are you approaching the social determinants? >> first, jay ludlam, when you
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get all that figured out, we will also get our dollars from cms. >> i would love that. >> yes, we have and when we think about medicaid transformation in virginia, first and foremost, we want to improve our members health and well-being within our medicaid program in the traditional healthcare services that we provided throughout time. but second, we want to improve our members health and well- being from the vantage of our medicaid program as part of a continuum of programs and services. this certainly includes a greater focus on population health and social determinants of health. as i said previously, we are now almost fully a managed-care state. in these pursuits, we will have as our partner our managed-care
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plan. that does as jay ludlam mentioned provide the sum much ability with what kind of care, and how you pay for health because we are doing these through our managed-care plan. i was say that for virginia, we are very much at the fact- finding stage. i am learning more about our members and learning more about our providers, and our providers connection to their community. one thing that we are doing is that for all of our medicaid expansion and our managed-care plan, we will be giving them a kind of a screening tool, and within the screening tool, we will have a question on social determinants of health. right after that, we will kind of know a lot more about our medicaid expansion in rowley's them! in rowley -- participants, and
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we are putting provider surveys out in the field to our care providers in the state, and in inclusive questions that get at what are the connections to your community? do you feel that you are kind of able to refer individuals who may need help in housing or need help for food to the appropriate connections? we are kind of saying that we are bought in, and we understand and have understood for a very long time that buying health is not the same as paying for medical services. but now, we are at the stage with what does that actually mean and how can medicaid play a role as we have connections to our members and to our providers? we have the partnership with our managed-care plan that also
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has connections into the community, and how do we bring that together with oh by the way , we are uniquely situated as an agency, that also has connections to members that we know to us. in fact the four walls of the clinic, they know through the housing and homelessness program. they know through other programs and we are in the midst of forming these partnerships both within our and within our medicaid agency, but with our sister agencies across the state. we are very excited. >> one of the key design elements for north carolina as we move to managed-care is having the benefit in our journey of being relatively new
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to this trip, that we don't want to create a new silo for social determinants, and we want to be sure that we are really identifying the value and whether or not that is a financial value or a quality value. i think it is important for people to understand that we are working very hard to make sure that our quality measures are aligned and not different for interventions that involve social determinants. similarly, in order to support that, we need new mechanisms to capture that information. these assessment questions are different and it -- an invoice for an air filter to treat asthma, how do we get that into the state system so that we can combine it with all of the other information that we have
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access to, including those sister agencies, to push it back out to the providers and health plans, and is a big focus of what we think is i work for the next 2-3 years. >> in the remaining time, i want to invite anybody who had any questions for our panel is to come up to one of the numbered microphones, and as you do that, i like to pose a final question for the two of you. obviously the journey toward better managed-care has been one that is been coming for a long time. the train has left the station on this, but obviously every different administration here at the federal level does get to put the imprint on the program and the direction that the things are going. i know that fema has talked a lot over the past year and a half about a medicare program that reflects flexibility,
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transparency, accountability, and integrity. let me reflect that back to you and say what does that mean for you and what does it mean in your program, and how do you see those issues playing himself out? >> i was say that all of those are consistent with how we run and want to run our medicaid agency. i was say that in particularly, just as where we are on this continuum of transformation our medicaid agency, one thing that i think virginia very much is in alignment with the administration, is to focus on evaluation. for too long, i think that states implants and researchers haven't done such a great job
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in the medicaid space, and often that is because of data rather than kind of lack of interest. i think we are at a juncture where we had the data, and we had the experience, and it would be irresponsible for all of us without evaluating where we are right now and what lessons can we learn from that? what is working and what is not as i think ultimately, we have a responsibility to our state and for our dollar spent, and to our members for the care they receive, so i would end with a focus on how we are going to move with additional information.
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you know we have really embodied the transparency of those policy papers that i was discussing earlier. i think that accountability is another area, i think that with all of this, data, there will be a lot of questions that will be asked from that. and then, there will need to be policy answers that are derived from it. i do have to say, just from being a state employee, there is nothing like the budget process to focus the mind on making sure that you are identifying priorities and raining accountable to your citizens. >> let me dig a little bit further on those points, you know, a lot of people throw around the term data. or, data analytics. i just, yes, we have done it. >> [ laughter ] >> what does that really mean in terms of an interaction and
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relationship between states and plans and providers? because, for data to be meaningful, it has to be collected. it has to be collectible, collected, and it has to be relevant, the right data, and then you have two, once you have collected the right data, you have got to figure out, what do we do with this? so, what do we do with this? and, how can plans and our relationship with providers, who are in a lot of cases providing the data, how do we get to where we are? >> you know, i think that we have spent a lot of time struggling to actually, get the data, right? you know, we were having trouble figuring out what the
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member experience is, because, we have silos of data, that exist, at various components of our medicaid agency. and i think that, in many if not most states, we are beginning to get kind of a complete picture, of our member experience as they move through medicaid. and, i think kind of just at the very summary level, about what do you first do with data? you say look, i can now look at, taking any given member, and kind of looking at their experience, across our program. and that in and of itself, is informative to our policies going forward. i would say, now that you have the data, what do you do with
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the data? you prefer my lot of research analysis on it look at the member experience, but you pay on the data. you know? you are not going to get the data that you need until you kind of pay on the data, and that involves a lot of work, with our health plan partners, to make sure that we are paying on the right thing that what we are seeing is real and what we are seeing in the data is actually reflected as a real experience of our members. but, we get to get to a place, where we can agree on, what we want the member experience to be, what does that look like when we see it in the data? and, how do we pay on that data?>> the issue of data, and, turning it into actionable information, is something that
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we wrestle with all of the time. i think that it goes back to the point that one of the reasons why north carolina probably will not see a large staff reduction is we are going to see and need a number of analysts. a number of support staff, to support the influx of all of this data, and turning into actionable information. i think that as it works with health plan, i think that there will be in the future robust conversations between the state and the health plans about what is it that we are seeing, and what is it that they are seeing, and what does it mean and what are we going to do about it? whether it is on the individual level or whether it has been there call centers and they are not in their ability to pick up the phone fast enough, there is going to be a lot of things that are going to come out for it -- come out of it, but right
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now, connecting data, quality, and finance, it is just kind of our focus. and, there seems to be a lot of power when in understanding the intersection, one -- with the aspects of that program and really it will take the next generation of medicaid leaders to figure out how to change policy, or, direct you know, the flexibility again of the managed-care contract in the ways that address the issues identified through the data. and i am a little worried, silently, on a stage. [ laughter ] >> [ laughter ] not private. >> you know at some point from an accountability standpoint,
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you should have known you had the data. and, data is just bits and bytes information derived, i think that that is the big difference. when you talk about, data, data, data, it is about how you convert it to information and whether you have the operational, or, administrative capacity to turn that into action. >> the plural of anecdote is not data and the plural of data is not necessarily information. >> yes, we are pretty much out of time, but i want to and with a very quick high-level opportunity for both alan and jay to say, what is one take away, what is one thing that you are extremely excited about, extremely proud about or really just a broad take away that you want people to know, about your state, your medicaid program, and your journey? >> sure, you know, i think, in virginia, we were particularly
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excited on january 1, and, to jump off from there. you know? we are at this point, at which in virginia, we have a continuum of coverage. we do not have individuals falling in, out of insurance gaps. as i look out into the plans here, you know, one thing that really is not great for an individual's health, as if they are going in and out of health insurance coverage, and therefore, care. so, i am very much looking forward to and in virginia, our ability to move together as a state. but also as a medicaid agency, to really serve our members better. and, you know, very much looking forward to that.
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>> in 378 days, we will launch our first phase of managed care and we will begin transitioning, 400-600,000 n. carolinians from their program that they know, today, and to this new thing which is managed care, and so, our staff has been, absolutely focused on the beneficiary, making sure that their transition into managed-care is smooth, and that nobody gets hurt, due to an administrative change of the delivery system. that would be appalling frankly. so, you know, from the leadership of dave richard the medicaid director and secretary mandy: we have all been focusing on that transitional moment, and, on the beneficiary primarily but providers run businesses, and, it is
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incredibly important for us to support them in the transition. so for us, it is, i look forward to copying and pasting, happiness, and looking forward to things. but right now, it is just remaining vigilant around this transition. to managed-care. >> all right. fantastic. i wish that we could spend all day doing this but we cannot because there is other stuff going on but please join me in thanking both jay and ellen.>> [ applause ] i think that we have a 10 minute break until the session starts but please do not forget to rate this session on your app, and, given as many stars as you physically can. thank you everybody. >> [ laughter ]
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coming up thanksgiving weekend on the c-span network, thursday at 8:00 pm network supreme court justice elena kagan followed by john roberts, friday at 8:00 p.m. eastern, former new jersey governor chris christie and others, discussing the opioid epidemic saturday at 8:00 p.m. eastern photojournalists talking about their favorite photographs taken on the campaign trail. and sunday at 6:30 p.m. eastern, gun laws and self- defense. on book tv on c-span capital two, -- 2, stanley mcchrystal talks about 13 great leaders. friday at 8:00 p.m. eastern on afterwards, political writer derek hunter, saturday at 8:00 p.m. eastern, lindsay a dario talks about photos that she has taken in the middle east. and, sunday 10:00 p.m. on afterwards, josi antonio varga, one of american history
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tv on c-span 3. on american artifacts, celebrating the first english thanksgiving, at berkeley virginia near jamestown. in 1619, friday at 6:30 pm on the presidency, reflections on former first lady barbara bush. saturday at 8:00 p.m. eastern on lectures in history how the pilgrims became part of america's founding story. and, sunday 9:00 a.m., constitutional scholars, scarlet -- philip and rita talk about how the u.s. constitution defines impeachable offenses for the president. thanksgiving weekend on the c- span networks. c-span, where history unfolds daily. >> in 1979, c-span was created as a public service, by america's cable television company. and today, we continue to bring you unfiltered coverage of congress.
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the white house. the supreme court, and public policy events in washington dc, and around the country. c-span is brought to you by your cable or satellite provider. next on the presidency, ronald reagan's attorney general edwin makes talking about the 40th president's views on communism and his relationship with pope john paul the second. at a conference organized by the white house writers group. the program was also recorded as part of the hoover institution's video series. uncommon knowledge. peter robinson moderating the conversation, just over half of an hour. ronald reagan and pope john paul ii, partnership that changed the world. today in washington at a conference devoted to that subject. with us today and eyewitness to the relationship between president reagan and pope john


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