Dr. Caroline Carney of Magellan Health: “Scaling back the regulations that govern the ways we provide care”

Establishing payment parity between primary care, behavioral health and specialist visits. This has the potential to change the dynamic between primary care physicians and their patients. Primary care providers have to read and act upon tests like X-rays in real time, often before any “official” reading is done by a radiologist. Yet, the radiologist is […]

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Establishing payment parity between primary care, behavioral health and specialist visits. This has the potential to change the dynamic between primary care physicians and their patients. Primary care providers have to read and act upon tests like X-rays in real time, often before any “official” reading is done by a radiologist. Yet, the radiologist is reimbursed at higher rates. As a nation, we’ve begun to offer student-loan forgiveness to make primary care more attractive as a profession, given the shortage of primary care physicians.


As a part of my interview series with leaders in healthcare, I had the pleasure to interview Caroline Carney, MD, MSc, FAMP, CPHQ, Chief Medical Officer, Magellan Health and Magellan Rx Management.

Dr. Caroline Carney is a board-certified internist and a board-certified psychiatrist. She joined Magellan Health in 2016 and serves as Magellan Health’s Chief Medical Officer, while continuing as chief medical officer for Magellan Rx Management. Her previous experience includes the role of SVP Chief Medical Officer of Magellan Behavioral Health and Magellan Specialty Health. She served as the chief medical officer for regional health plans where she gained experience in Medicaid, Medicare, Exchange, and commercial populations. She has served as the medical director for the Indiana Office of Medicaid Policy and Planning, helping to launch the Medicaid expansion product as well as the behavioral health transformation for the state’s community mental health services. While in Indiana, she served on the Governor’s Mental Health Commission. She is a frequent speaker about behavioral health services, integrated and collaborative care, and the importance of self-care during the pandemic. Dr. Carney is a published author and co-author for over 100 peer and non-peer reviewed publications focusing on issues surrounding comorbid medical and behavioral health conditions. She was a tenured associate professor of Internal Medicine and Psychiatry at Indiana University. She started her medical and academic career at the University of Iowa where she earned her medical degree, as well as a master’s degree, and directed the Med-Psych residency program. She continues to engage in regular clinical work through supporting the behavioral health team at a federally qualified health center.


Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

One day when I was five years old, I was sitting in my grandparents’ old country farmhouse with my Aunt Rita, who was a nurse. She taught me how to feel for the radial pulse — from that point on, I was captivated.

When I graduated from college, I had the opportunity to enter a writing program, or go to medical school. I came to the realization that a doctor could be a writer, but a writer couldn’t care for individuals in the same way. While words can move and inspire people, my calling was toward the healing arts. I knew I had made the right decision the summer between my first and second years of medical school when I worked on a research project interviewing the families of individuals with eating disorders. I was hooked for good — it is an eye-opening experience and a privilege to be a participant in an individual’s journey through health, illness, and even death. I studied and practiced both internal medicine and psychiatry, and still carry with me the stories of those I’ve encountered along the way.

What do you think makes your company stand out? Can you share a story?

Magellan’s frontline staff are the heart of this company and are the kind of people who bring their best to our members, no matter which line of business they serve. The advocacy work these teams do on the job, and through volunteerism is impressive. I was recently very touched by a note sent to us from the wife of a young father who had suffered a brain injury — she even included pictures of him in the hospital, and later with their kids. Her note spoke of the gratitude she had for one of our case managers who had assisted the family. There is nothing more meaningful than that.

Another group of our therapists working in our federal division provide confidential counseling for military members and their families to help them cope with the stresses of deployment and other issues that are unique to the military lifestyle, including homesickness, relocation adjustment, grief and loss. Magellan’s high-touch clinical programs make me proud.

Secondly, our company is re-imagining much of the work it has traditionally done and embracing new models of care and service. This transformation couldn’t be done without the vision and support of our leadership team. Expect great things ahead for how we recast care across behavioral health, pharmacy and specialty services! The commitment to industry leading change starts at the top and will be carried out by compassionate and highly capable people.

For example, our pharmacy benefits management division, Magellan Rx, developed a highly integrated, high-touch, high-tech approach through our LiveVibrantly programs that combine advanced analytics to flag members who are at high risk for non-adherence, or who are being treated outside of evidence-based practices. Then, we pair providers and patients with experienced pharmacists, nurses, behavioral health professionals and health coaches to provide customized solutions based on their needs. Our NPS scores for these programs are outstanding!

We’re also pursuing innovative collaborations around behavioral and specialty health that are building resilience in children and adults. One example is our relationship with Neuromotion, Inc. — known more commonly as Mightier. We teamed up to evaluate a video game platform that will help children with autism spectrum disorder develop emotional skills and learn how to reduce stress in a fun and highly effective way. Children learn lifelong emotional skills through play, while caregivers gain a personalized dashboard that tracks the child’s progress as well as access to an online parent community and one-on-one coaching with a licensed clinician. More than 25,000 families have participated in Mightier’s other programs, and 75% have reported improvement in their child’s emotional strength.

What advice would you give to other healthcare leaders to help their team to thrive?

Give employees space to innovate and create, especially frontline employees who experience firsthand the challenges that people face. Not all innovation must take place within the confines of the workplace — and indeed, during the COVID-19 pandemic, innovation is occurring outside the walls of the traditional workspace. Giving staff the freedom to think outside the box and the tools needed to support their efforts is one step toward attracting and retaining cognitively diverse talent.

Are you working on any exciting new projects now? How do you think that will help people?

One exciting initiative that we launched this year is Magellan Health Studio, which was designed to accelerate the development and delivery of next generation products for health plans, healthcare systems, providers and ultimately patients. This expands on Magellan Rx’s Studio which has been bringing innovation to our pharmacy benefits management (PBM) for the last few years. Through Magellan Health Studio, we’re solving healthcare’s most complex issues by testing new care delivery models and creating products that address the behavioral health and physical needs of patients. As COVID-19 has upended our “normal” everyday lives, overall mental health has been greatly challenged, leaving many feeling depressed, angry, sad and hopeless, making it absolutely clear that behavioral and mental health remains a critical societal need. With Magellan Health Studio, we aim to bring holistic, innovative solutions to the industry, leading with behavioral health, that will transform the healthcare experience for patients.

Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the U.S. healthcare system is ranked as the worst among high-income nations. This seems shocking. Can you share with us three to five reasons why you think the U.S. is ranked so poorly?

The first reason is tangentially related to the healthcare system — it’s the sheer prevalence of obesity, chronic disease, sedentary lifestyles, and use of substances. In order to change theburden this puts on the healthcare system, we need to see societal change that supports healthy eating of fresh foods, smaller portions, exercise, mindfulness and limits access to the kinds of things that hurt us, from vaping, flavored tobaccos, to illicit opioids. We need to address homelessness and food insecurity. This is bigger than the healthcare system, but intimately linked to the kinds of outcomes we can achieve in reaching health.

Related to this is a lack of health literacy and social determinants of health (SDOH) that significantly affect health outcomes in the U.S. The stories are painfully familiar: a patient whose blood pressure levels were worsening simply because he didn’t know he was supposed to take his medication twice a day, not just once. Today, our society holds the provider responsible for solving issues with health literacy that impact health, yet we don’t give providers the resources they need to address health literacy or other SDOH, such as lack of stable housing or access to healthy food.

Up until recently, our healthcare system has been fully fee for service, which means that reimbursement is based on the number of procedures, or visits, or interventions — not necessarily the quality of the work being done, or the outcomes. Through accountable care organizations (ACOs) and value-based care models, we are beginning to see a paradigm change, and I’m hopeful that the outcomes we see are more than financial. It is my true wish that we appropriately treat people with the right interventions at the right times, which will lead to the best outcomes.

The system is often confusing and challenging for individuals to navigate. Even as a physician and an executive, I find it’s challenging to access care — sorting through pages of providers, looking for one that takes the type of insurance, waiting for appointments that come at some point in the future, understanding co-pays from co-insurance from deductibles. This isn’t too big to solve, it takes health literacy, systems of care and navigation support for both patients and providers. Just think what focus groups could tell us about how to share information with them!

Another challenge is the high out-of-pocket costs consumers pay for care. A survey earlier this year found that when Americans have insurance, nearly 1 in 3 fear they will be unable to afford their care — and that was before the pandemic. The same survey found that 20% of Americans delay care due to costs. Now, we have delays in care because of costs and the pandemic — this is a recipe for poor future outcomes.

Finally, it has to be mentioned that underlying all of these issues is the lack of providers, especially for behavioral health and primary care. Further, providers are concentrated away from rural areas, making it even more challenging for some Americans to get needed services. While COVID-19 has led the shift to telemedicine, it certainly hasn’t increased the availability of providers to see those in need, and recent data show well-child visits are lacking. Shortages of nurses, particularly in the South and West, are projected through 2030, and we’re experiencing shortages of ancillary services such as home health aides and laboratory workers. This is an issue we must address not just to protect access to care, but also health outcomes.

You are a “healthcare insider.” If you had the power to make a change, can you share five changes that need to be made to improve the overall U.S. healthcare system? Please share a story or example for each.

Five changes I would love to see occur include:

Establishing payment parity between primary care, behavioral health and specialist visits. This has the potential to change the dynamic between primary care physicians and their patients. Primary care providers have to read and act upon tests like X-rays in real time, often before any “official” reading is done by a radiologist. Yet, the radiologist is reimbursed at higher rates. As a nation, we’ve begun to offer student-loan forgiveness to make primary care more attractive as a profession, given the shortage of primary care physicians.

Scaling back the regulations that govern the ways we provide care. The pendulum has shifted far in regulatory and administrative complexity — driven not by patient outcomes — but reporting requirements, mandates and other pre-requisites. As a result, some providers, especially behavioral health providers, are moving toward cash-only arrangements with patients to avoid billing appointments through insurance — and they have patients who are happy to oblige. This is an issue we need to address to avoid situations where access to specialized care is only available to those who can afford to pay their providers directly. Shifting more toward measurement-based care and outcomes, and less on front-end paperwork may help this.

Encouraging atypical partnerships that promote value. If we want to fuel transformative change in healthcare, we must encourage providers to establish creative partnerships with technology, retail and pharmaceutical companies, higher education institutions and government agencies to bring new solutions to the marketplace focused on outcomes. At Magellan, we’re continually keeping an eye out for tech-enabled, emerging disruptors in the healthcare marketplace to determine: How can we partner with them to accelerate value creation in the future? One example is our work with the “Yale Innovation to Impact” program that explores ways to combat substance use disorder with the help of biomedical devices and apps for smart devices.

Encouraging analyticdriven, targeted interventions. Teams at Magellan are focused on aligning the right services to the right individuals — whether it is through stratifying who should have what kind of intervention, to knowing what the best method is to reach and engage the member and support the provider. Interventions like these will ultimately lead to better outcomes without adding additional costs.

Bringing consumers into the conversation around health policy and best practices. I was part of an opioid stewardship panel sponsored by the National Quality Forum (NQF) a few years ago. The NQF invited consumers to be part of the panel and share their perspective around ways to prevent opioid use. Their voices of the good experiences and the bad experiences were enlightening and shed a different light on the work at hand. We need to collaborate with a diverse group of consumers to develop a healthcare system that works. Diverse groups mean inclusion across racial and ethnic factors, workers and unemployed, across age groups, across political perspectives, and to also include providers. When we don’t take the time to gain consumers’ perspectives around how care is delivered, we risk gaps in knowledge that prevent us from designing a system that exceeds patients’ needs.

Creating a more patient-centric model for primary care and reimbursement. Today, patients typically receive one preventive visit per year through their health plan, yet the provider may have as many as 15 quality metrics to address in a single visit. This raises the risk that crucial conversations around health may not take place because there is so much to cover in a single visit. By better aligning the interests of the patient with those of the payer and provider in designing value-based models of care, we will strengthen our ability to identify patients’ whole-health needs and provide the right interventions to the right patient at the right time.

Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

There are so many opportunities for healthcare leaders, corporations, communities and government agencies to collaboratively design solutions that improve the health of our communities. We witnessed the power of collaboration between government and healthcare after Hurricane Sandy in 2012, when thousands of New York residents suffered from PTSD due to the emotional distress they experienced after the storm. The Mental Health Association of New York City reached out to Magellan to develop a plan to offer computerized behavioral therapy services for residents in distress via smart devices. Nearly 60% of those who received treatment demonstrated at least a 24% improvement in PTSD symptoms. It’s an approach made possible not only through advancements in technology, but also by bringing the right people to the table to develop out-of-the-box solutions.

Currently, we’ve opened crisis lines to frontline healthcare workers dealing with COVID-19. The average length of conversations is 20 minutes, and we’ve learned firsthand the issues that these valiant providers face daily in being able to do their jobs.

Using behavioral economics to incentivize the healthcare behaviors we wish to see among employees and in our communities could also go a long way toward improving health. Consider that medication non-adherence accounts for up to 50% of chronic disease treatment failures and more than 100,000 deaths per year. We partnered with a company whose app monitors patients as they take their prescription and offered patients a 300 dollars gift card for completing this 84,000 dollars treatment. In a recent pilot program, 100% of participants adhered to their treatment regimen, compared to a statistically significant lower number who were controls. What if employers were to apply behavioral economics toward incentivizing the health behaviors they wish to see in their employees, such as by making gym membership dependent on demonstrated use of their membership?

How would you define an “excellent healthcare provider”?

Excellent healthcare providers artfully balance listening, the human touch, and understanding current diagnostic and treatment pathways. Digital technologies should be considered adjuncts, not cure-alls. Excellent healthcare providers lead with a noble, strong and powerful purpose, not one that is only financially motivated. They respond with agility to the needs of their communities in a transformative environment. They think about patient touchpoints in new ways, and they seek to meet patients where they are by providing care in the settings and formats that best meet patients’ needs. They are open to nontraditional partnerships, approaches, and structures that drive innovation and value.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

My kids will tell you that I have two: “Walk it off” and “Everything in moderation.” The first has wide applicability — it started as a way to change thinking that every skinned knee my kids had was a hugely traumatic event — put things in perspective. Not everything needs an immediate intervention, whether a minor injury or a daily frustration — walk it off, take a breath, don’t over-treat or overthink.

The second applies to life in general, especially in how we consume food or drink, how we spend, what we really need to have. Life is no more about starving yourself than it is about living in excess. The applicability to the healthcare world is evident.

How can our readers follow you online?

Please follow me on LinkedIn. You can also find articles I’ve written on a number of healthcare topics magellanhealthinsights.com. To find out more about Magellan visit, magellanhealth.com.

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