CDC’s 6|18 Initiative is bringing together state Medicaid and public health partners to improve health and control health care expenditures for six high-burden, high-cost health conditions by adopting evidence-based prevention strategies. North Carolina is focusing on reducing tobacco use under the 6|18 Initiative, as well as efforts to prevent type 2 diabetes and unintended pregnancy.

CHCS recently spoke with Kelly Crosbie, MSW, LCSW, senior program manager of Health Transformation in the Division of Health Benefits (Medicaid), and Sally Herndon, MPH, head of the Tobacco Prevention and Control Branch in the Division of Public Health, to discuss how they are creating cross-agency synergies to promote tobacco cessation in North Carolina. Ms. Crosbie and Ms. Herndon, who are both in the North Carolina Department of Health and Human Services, are using their 6|18 efforts to implement tobacco prevention and control strategies through collaboration and relationship building.

Q: How would you describe the context in North Carolina for your work on tobacco cessation? Given that context, why did you think 6|18 would be valuable?

Kelly Crosbie (Medicaid): The timing of North Carolina’s participation in the 6|18 Initiative aligned with our transition from fee for service (FFS) to managed care, which will be complete in 2019. This presented an opportunity for us to partner with public health on population health improvement efforts, in order to stretch beyond standard billing and coding and to consider available, but underutilized, Medicaid levers to impact population health.

Sally Herndon (Public Health): North Carolina is the leading tobacco-producing state in the nation, but despite this, the state government has been actively engaged in tobacco prevention and control since 1990. Currently, 43.3 percent of Medicaid enrollees are smokers, compared to 17.9 percent of all state residents. Tobacco-related health care costs total more than $3.8 billion per year in the state, including $931.4 million in Medicaid expenditures. Given these data, we saw the 6|18 Initiative as an excellent opportunity to reduce tobacco use and tobacco-related health issues in the Medicaid population.

Q: Describe the benefits to your participation in 6|18. What aspects of the 6|18 Initiative did you find most useful in strengthening the collaboration between Medicaid and public health?

Kelly Crosbie (Medicaid): The opportunity for cross-agency collaboration and alignment has been invaluable. Hearing directly from other states about managed care organization (MCO) contracting processes and potential pitfalls and getting access to examples of contract language and MCO performance improvement projects have also been really helpful.

Sally Herndon (Public Health): As North Carolina Medicaid is transitioning to managed care, being part of the 6|18 Initiative provided focused and regularly scheduled time for planning, data sharing, decision making and implementation. The concrete guidance from national experts has been instrumental to our progress. For example, Deirdra Stockmann from the Centers for Medicare & Medicaid Services provided a quick affirmative answer regarding whether the state can require its MCOs to contract with the state tobacco quitline vendor to deliver cessation services. This was a breakthrough moment that led to our adoption of the one quitline approach in North Carolina.

Q: How was the level of collaboration between North Carolina’s Medicaid agency and Tobacco Prevention and Control Branch impacted by the 6|18 Initiative?

Sally Herndon (Public Health): Before participating in the 6|18 Initiative, North Carolina Tobacco Prevention and Control Branch had the Medicaid match, which allowed us to draw down federal Medicaid funds to pay for 50 percent of the administrative costs for Medicaid enrollees using QuitlineNC services. However, the relationship between public health and Medicaid was simply “on paper” to ensure that the “match” protocol was being met. Since joining the 6|18 Initiative, we know whom to call because we’re now familiar with names and faces. We have developed relationships with our sister agencies that can serve us down the road.

Kelly Crosbie (Medicaid): Participation in the 6|18 Initiative has promoted mutual respect for each agency’s unique expertise.

Q: How were the roles that North Carolina Medicaid and public health each play in the 6|18 partnership determined and what benefits did you see in the designation of responsibilities?

Kelly Crosbie (Medicaid): So many of the levers for population health improvement require coordination within Medicaid: quality improvement, billing and coding, rate setting, and more. 6|18 has encouraged and propelled connections among sometimes disparate internal silos. While the 6|18 Initiative encourages inter-agency collaboration between public health and Medicaid, it also increased intra-agency collaboration within Medicaid’s various internal units.

Sally Herndon (Public Health): The broader public health team working with the Tobacco Prevention and Control Branch contributed leadership and clinical expertise as well as systems management skills to the collaborative efforts. This enabled the Tobacco Prevention and Control Branch to focus on providing technical expertise and accelerated the momentum of NC’s 6|18 work.

Q: Can you describe specific examples of early progress or “wins” that have come about as a result of your participation in the 6|18 Initiative?

Sally Herndon (Public Health): After conversations with the Health Secretary, North Carolina agreed to support one quitline under Medicaid managed care: QuitlineNC. If North Carolina had not participated in 6|18, there likely would have been a number of separate quitlines serving our Medicaid population, with variable services, little opportunity for a coordinated approach to promote services, and ultimately reduced referrals and access to cessation services.

North Carolina is also exploring the opportunity to have a standing order of over-the-counter nicotine replacement therapy for Medicaid enrollees who want to quit smoking. This would reduce a number of barriers to accessing tobacco cessation.

Kelly Crosbie (Medicaid): Technical assistance from experts who provided sample managed care contract language and stories from peer states that struggled with multiple quitlines solidified our argument that one quitline would be the best approach to help North Carolina produce tangible population health benefits. From engaging the Health Secretary with the evidence base to working with the Deputy Attorney General on contract language, approaching leadership in an informed and strategic way enabled North Carolina’s progress under 6|18.

Q: What other experiences or advice would you like to share with other states that may be considering participating in the 6|18 Initiative?

Kelly Crosbie (Medicaid): In addition to gaining leadership support, work to sustain it by regularly engaging leadership in both public health and Medicaid for their expertise as well as to share project progress and updates. Measure progress and outcomes and also keep an eye on the ultimate goals and how each activity leads to these shared outcomes.

Sally Herndon (Public Health): Clear, persistent communication is key and having project management support helps facilitate this both internally and with external stakeholders. Keep the work moving, but don’t get frustrated by the time required. The pace of moving population health forward through two government divisions can become discouraging. While you may not see progress week by week, you will see gains over longer periods of time. As you make progress, continue to look at what other states are accomplishing and consider adding additional activities or priority areas. 6|18 presents a framework and approach that can then be applied to a variety of population health challenges.

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