Government service offers Fellow a chance to help millions

Building on a successful career in the federal government, Mandy Krauthamer Cohen, MD, MPH, FACP, was recently appointed secretary of the North Carolina Department of Health and Human Services, a role that the former leader of ACP's Council of Student Members said lets her continue to help not only the patient in front of her but potentially millions.

Dr. Cohen began her career in government service before her medical career, working for then-Sen. Edward M. Kennedy during college when he was on the Senate Health, Education, Labor, and Pensions Committee. During her time with the senator, she worked on Medicare and the Health Insurance Portability and Accountability Act and what is now called the Medicare Advantage program at the Centers for Medicare and Medicaid Services. “I had always had an interest in going into medicine because of my mom and her clinical background, but it was the experience working in the Senate that helped me see a path that could combine the clinical and policy worlds, and how I could be a valuable link between those worlds.”

Her tenure in federal government culminated as chief operating officer and chief of staff at CMS during the Obama administration, helping to implement the Affordable Care Act.

That first job gave her a taste of thinking about policy, she said, as did her earliest efforts at ACP. “My time at ACP gave me that broader perspective of medicine, the policy world beyond the clinical practice of medicine,” Dr. Cohen said. “And I was really inspired by that in terms of the impact you can make.”

Dr. Cohen added that she entered medicine at a time when older doctors often told her about the challenges of practice. “So I thought that I would join the medical field, but do it in a way that I could help reform the system so it would work better for the people it's meant to serve.”

She left CMS in the days before President Trump's inauguration, joining North Carolina's Department of Health and Human Services on Jan. 24, 2017.

“I couldn't be more thrilled about my role here at the state level. I loved the federal government. But what I love about the work at the state, you feel close to the community, to individuals. I get to travel around the state and see in a much more tangible way the impact of the work that my department does,” Dr. Cohen said.

She oversees a department of 15,000 employees, a $20 billion annual budget, and duties that span oversight of the state's Medicaid program, three psychiatric hospitals, and 10 other facilities such as drug treatment centers, as well as the department's human services work, including SNAP and other social services such as child protection and welfare.

“That's been exciting to me to think really broadly about health, rather than just the payment of health care,” she said. “When I was at CMS at the federal level, I was very focused on Medicare, Medicaid, and marketplaces and insurance coverage.”

The shift has made her consider health care in the broadest possible sense, beyond the four walls of a doctor's office, “and really think about what drives health and health outcomes. It's about more than health care. It's also about food stability, transportation, safe housing.”

Her most pressing priority to date has been the opioid crisis that afflicts every state. North Carolina's Wilmington and Charlotte are both on the top 10 list of affected cities in the U.S. Upon taking state office, Dr. Cohen began to implement a plan to stem the tide.

One of her first steps was sending a letter to doctors and other prescribers to appeal to them on a professional level. “This crisis was started by increasing use of prescription opioids. Our own prescription pads are part of the issue,” she said. She asked physicians to use best practices as described by the CDC, as well as the state's electronic database to track opioid prescribing.

More recently, Dr. Cohen launched a larger state-wide action plan, one driven by a partnership with law enforcement, education, and health care professionals, with very specific goals and metrics that commit to a 20% reduction in opioid deaths over the next several years. “It's an ambitious goal, but I believe it's achievable,” she said.

The action plan changes a number of rules about prescribing in the state Medicaid program to make it much easier to access nonopioid pain control methods. “We can't lose sight that pain is real; we need physicians to treat pain,” Dr. Cohen stressed. “We need to make sure that we are exploring alternative pain modalities, whether that's physical therapy, acupuncture, chiropractic care, or nonopioid medications.”

She is striving for this goal amid a politically acrimonious environment. To implement her vision, she presents herself to the state's General Assembly as a pragmatic, practical, solutions-oriented leader.

“I'm focused on the work of making the health of this state better,” Dr. Cohen said. “We have a lot of care goals in that vein: How do we get more value out of every dollar we spend? We are moving the needle on health.”

She also focuses on achieving goals shared by opposing parties, not only on opioids but rural health and children's health. “I look for places where there is a lot of alignment, and we can move the ball forward as much as possible,” she said. “That has allowed us to be already successful in the first six to eight months that I've been here.”