Exploring the Overlap Between Public Health and Population Health, and the Potential for Public/Private Partnerships
Mandy Cohen discusses the need for integration between public and private sector health entities in order to achieve common goals and shared financial responsibility to “buy health” for whole-person care of populations.
- Mandy Cohen, MD, MPH &
- Namita Seth Mohta, MD
Summary
North Carolina’s Secretary of Health and Human Services, Mandy Cohen, MD, MPH, recognizes distinctions between public health efforts by public-sector governmental entities and the population health endeavors of private-sector care delivery organizations, and describes her efforts to facilitate a shared vision to buy health for the people by aligning all resources, from all sectors, around health.

Namita Seth Mohta, MD, interviews Mandy Cohen, MD, MPH, Secretary of the North Carolina Department of Health and Human Services.
This is Namita Seth Mohta for NEJM Catalyst. I’m speaking today with Mandy Cohen, Secretary of the North Carolina Department of Health and Human Services. Prior to this, Secretary Cohen worked at both CMMI [Center for Medicare & Medicaid Innovation] and CMS [Centers for Medicare & Medicaid Services], most recently as the Chief Operating Officer at CMS.
Although we can discuss many topics given your expertise, Secretary, today we are going to focus on two important areas. First, I’d like to get your insights on this overlap between public health- and population health–related initiatives, and second, I look forward to discussing both the opportunity and the challenge of public/private partnerships as they pertain to providing integrated whole-person care in communities.
Let’s start by setting some context. Tell us a bit about your day-to-day job as secretary and describe what some of your roles and responsibilities were at CMS and CMMI.
I was at CMS for about 7 years. I had a number of roles there, at various times. At the Innovation Center, I was head of Stakeholder Engagement at the very early days at the Innovation Center, before we even launched any models, and it was a great opportunity to build a new entrepreneurial effort within the government. I spent the last 2 years of the Obama administration as the Chief of Staff and Chief Operating Officer, which means that I was running the day-to-day of CMS in terms of decision-making and making sure that all the trains ran on time.
Here, in my role as Secretary of the Department of Health and Human Services for North Carolina, it is quite an extensive role. I have about 17,000 employees and an annual budget of about $20 billion, and a lot of that is the responsibility over our Medicaid program, but we also oversee public health, mental health, economic services — those are TANF and LIHEAP, SNAP (food stamps) — and also oversee early childhood education efforts, and we also run some of our own state-operated hospitals, psychiatric hospitals, and residential homes and skilled nursing facilities. It’s quite a range, and that’s what I love about the job; I’d say the day-to-day of the job is very varied.
When I speak with leaders who work for the public sector, they use the term public health; when I speak with leaders who work at health systems, they use the term population health, and when we dig deeper, we find out that they’re often referring to the same set of problems and challenges and also refer to the same basket of solutions. From your perspective, help us understand how you define these two terms and what the relationship is between the two of them.
Sure, let me start with public health; that is something that our team oversees here in the division of public health, as well as the many local health departments here in North Carolina. Public health is extremely varied. You could have things like environmental health, where folks are going into local restaurants to make sure the food is going to be cooked safely and there are good hygiene practices. It could be around water quality, where we have scientists who are making sure that our well water is safe for folks to drink. Other times, it’s our epidemiology team responding to outbreaks. Sometimes, it’s other public health crises, like some of these new lung injuries around vaping that we are seeing, so that is a big chunk of public health.
But there is a chunk of public health that is also thinking about high rates of obesity or smoking or diabetes, and that is where the overlap with population health is as it is traditionally thought about by folks like myself, who are doctors, and in the delivery system. How do we think about driving toward health for a population of folks? That’s separate from all those environmental public health efforts and the outbreak issues, but really is thinking about overall health burden on a population here. One of the things to consider is what a traditional public health infrastructure can work toward and what is it that our health systems do and what role do they play here? And I think that both play very integral roles in moving forward. Now, they have different kinds of funding streams and different ways of interacting with communities, but I still think they’re driving at some of those same large goals, whether it’s reducing infant mortality or cutting the rate of teenage smoking. There are tools that each bring to the table in order to solve those hard problems.
Give us some examples of some of these tools that you’re referring to that the health system can use and/or what the public health system can leverage.
Sure, let’s take a specific example of infant mortality. We know that’s an enormously complex issue. When I say traditional and public health, they have a lot of tools, particularly around education campaigns. For infant mortality, you want to do good sleep hygiene campaigns, including “ backs to sleep” to make sure that you’re putting your babies on their back and talking about getting your prenatal care and such. Public health also does a lot of work around family planning, making sure that mom has a baby when she wants to have a baby. We know that is a strong indicator of her having a successful pregnancy, as well as that baby being well in their first year of life.
On the other side, let’s look at the delivery system related to infant mortality. In North Carolina we pay for half the births in the state through Medicaid, and so we also pay for a majority of the NICU care in North Carolina. We have levers and tools to work with the delivery system to get moms access to the prenatal care that they need because we know if they do that they’re going to carry the pregnancy to full term, make it less likely that the baby is going to be in NICU and make it more likely they make it to their first birthday. So there are different tools that everyone brings: public health uses more traditional education campaigns and we see them do a lot of primary care work in terms of family planning, and then the delivery system is focused around prenatal access to care, as well as at the time of delivery, making sure that goes well for mom.
What you’re describing is where I’m going to go next in our conversation, which is around the importance of partnerships. There are a lot of silos within our health care delivery system, particularly around medical care and social services, and so I would love to get your insights around public/private partnerships. What are some examples of partnerships that you have seen work well and what about them made them work well?
We very much are trying to bring all of those often-siloed players in the space together. I’ll go back to infant mortality: So much about baby’s ability to make it to the first year of life has to do with mom’s health and mom’s economic status. That starts to get into what is her educational attainment, does she has a job, does she have stable housing, does she have access to food, and so we would bring all of those together in my department. We pull a lot of those levers, particularly around supporting young working families and young children. We are trying to bring all of those things together, and we cannot do it alone, though, from government. We will do a huge piece, and we certainly have a convening effort, but it does take private/public partnership in order to move forward.
One of the ways we’re trying to do that in North Carolina is facilitating a literal knitting together of what’s going on in the health care system and what’s going on in the community. We’re doing it through an IT platform. Don’t get scared everyone out there; IT platforms, I know. I don’t always think they are the solution to everything, but for so long, our health care system and our community organizations haven’t interacted in a way that allowed them to share information and actually coordinate care of the same family that they’re helping, and so we are building a platform called NCCARE360. It is a private/public partnership, it has private-dollar investment with public setting the stage for how we move forward with it. We hope to have this one consolidated platform across the entire state by the end of 2020, where we will have the health care system be able to refer seamlessly to community organizations, community organizations be able to refer amongst themselves, and then back to the health care system, so we’re all sort of sitting in the same room talking together.
The challenge there is, obviously, this isn’t about technology. It is about working differently and having different relationships. That’s where I see a lot of the challenge in the important work going forward is to make sure that we’re not just throwing technology out there, but we actually are truly trying to build relationships and break down those silos and have folks work in a new way, because I that’s the only way we’re going to tackle some of these hard problems.
We can have some of the public health work, we can have the health system work, but unless we’re going to really get down into community — where folks live, work, and play — we’re not going to truly to be able to move the needle. So we’re trying to think about all of those levers in coordination, which is a big job, and which goes back to the first question you asked about, what do I do in my day-to-day. Talking about that vision and that alignment is critical, and I spend a lot of my time trying to articulate a vision of bringing folks together and breaking down those silos and why it’s important to do it so that we can align our resources and put our shoulder against some of these hard problems.
What are one or two other things that you are most optimistic about as it relates to care delivery transformation?
What I’m excited about here in North Carolina is the alignment of folks around driving toward whole-person care and trying to think differently about driving toward health. Often in the systems that I grew up in and learned in, we were focused on delivery of excellent health care, which I think is incredibly important, but we’re doing a little bit of a shift here, particularly in North Carolina to say, “Well, how do we align all of our resources around health?” And I want you to think about this: I use the term, “I want to buy health for the people of North Carolina.” That means using that $20 billion budget to drive toward that, but it’s not just this department. What I’m excited about in North Carolina is that I’m seeing hospital systems, I’m seeing community organizations, I’m seeing physician practices, I’m seeing public health departments, and social services all align and say, “Yeah, that really resonates, that drive toward health, and I can see where I fit into that piece.” So we are seeing all of that come together.
Now, it’s not easy and it’s not fast, but everyone can see the vision, and that alignment is critical. What I see is that we’re trying to align the incentives, like the way we pay for things, to facilitate that paradigm shift to health. We try to use the tools we have to say, “I’m going to buy health, and I want to pay for those kinds of things, and I want to reward you when you’re delivering those things.” I see that alignment here in North Carolina with our private payers in the commercial space, with Medicare, now Medicaid, and seeing everyone saying, “You know, that really resonates.” So that’s what’s making me optimistic about what’s going on here in North Carolina.
You raised a couple of key points. One is this critical importance of having a vison, having alignment around that vision, and then in front is to support the actual work that one needs to do to realize that vision; congratulations to you and the rest of your team for getting those pieces into place. The second comment that you made that I think is very important, is alluding to the fact that you’re all marching toward a payer-agnostic model, meaning that the large types of insurers that pay for care in this country — Medicare, Medicaid, the commercial — are all in service of better health and one kind of care, excellent care, for patients regardless of what type of insurance or coverage they might have. That is a bold goal that I congratulate you all for marching toward. Secretary Cohen, thank you so much for speaking with NEJM Catalyst today.
It’s been my pleasure. Thank you so much for having me.








