DHHS head seeks improved relationship with counties

In interview with Association, Cansler says DHHS needs to open lines of communication

• NCACC Board of Directors hears from new DHHS, DOR chiefs

As one of its initiatives, the NCACC strategic goals team charged with "enhancing the state-county relationship through effective communication and the development of a working partnership" is interviewing members of Governor Beverly Perdue's Cabinet and Council of State. Interviews will be published in the next several issues of CountyLines.

In late April, team members sat down with new Department of Health and Human Services Secretary Lanier Cansler.

You served as DHHS deputy secretary under Governor Mike Easley and now serve as secretary under Governor Perdue. What are the major differences you are finding in these different roles and different administrations?

"As deputy secretary I was basically responsible for the business functions of the department, which means I was concerned with the budget and business aspects. As secretary, obviously the buck stops here and I have responsibility for all aspects of the department. As far as the difference in the roles, as secretary it's much broader and much more involved in policy issues than I was as deputy secretary. While I can keep my finger on budgetary and business aspects that is not my role right now as much as is the overall policy and setting the direction for the department.

"As far as the difference in the administrations, Governor Perdue has a focus on job development and economic development for the state and she realizes for us to be successful in that arena that we need to have quality education and a healthy workforce. Much of her focus is on the health of our citizens. Having the healthiest state in the nation not only includes physical health but mental health as well. Governor Perdue gave me a mandate to make sure the way the department operates provides the greatest array of service that it can and to really focus on dependent care and making the workforce a healthy workforce for North Carolina. It starts with children and goes from there. To that end, Governor Perdue is very involved, very supportive in making sure that what we need to do within the agency we can get done.

"The Easley Administration had their priorities as well but I'm finding in this administration the flexibility we have to make the decisions we need to make and the support we get from the Governor's Office is much more focused."

What is the strongest talent you bring to managing this agency?

"I'm a CPA by background and I was in public practice for over 20 years, and much of what I did in public practice was healthcare work, in management in health care. I've served in the Legislature and had the opportunity to chair the Appropriations Committee for Health and Human Services as well as being on the Mental Health Committee and the Public Health Committee. I co-chaired with Senator Tony Rand when the Health Care and Resite Committee was established. Then I served as deputy secretary. I've had experience both from the outside looking in … and from the inside of the department."

What do you see as the role of county commissioners and the county manager in local programs and services?

"Obviously, the two areas I have the greatest impact on is the department of social services and the department of health in the local communities. Much of what we do is handle dollars that flow from the federal or state government. When you look at public health, local government is the major funder. State and federal dollars make up some of it but the majority of the dollars come from local government. When it comes to social services, local governments still fund a lot of the staffing. It needs to be more of a partnership between state government and local government with these types of services because as our population continues to grow and the population ages we've really got to be innovative in how we do things. One-hundred county governments can't be all over the board. You have to have some common goals and some common approaches because you don't want one county with a different set of rules and a different set of functions than another county. I think, working together, we can find more effective procedures and cost-effective ways to do things.

"In mental health we have to be willing to leverage every asset we have. We have a major shortage of substance abuse services providers, but we have a whole network of local health departments that do tobacco use prevention but we don't do a lot with substance abuse prevention. So we need to find ways to leverage those assets. It may take a little more money but we'll find a way to leverage those assets. When we have an infrastructure out there that can help us reach certain goals we need to use that infrastructure to the best ability we can, and that's going to require a partnership and close working relationship between the counties and state to accomplish this type of goal. We can't continue to build silos and whole new systems. We've got to find ways to use the infrastructure we have, reinforce it and make it stronger, and accomplish more with what we have.

"Substance abuse is an expensive proposition for us. We are sorely lacking in providers and have lost about half of the providers in the last several years because of reimbursement decisions the state had made. The expense of having to work with someone in that crisis situation of substance abuse is a lot less expensive if we make sure they don't get there to start with. I'm not naïve to think we can stop all of it but sometimes you can, and if we can find proven methods to do that we should. We've really got to move our whole healthcare system from a system of dealing with crisis to a system of preventing crisis. A lot of that comes back to public health and being able to work with people early on that are high risk to keep them from getting where they are going to go. And again so much of that comes back to grassroots and working in the community, and counties are best at that."

How can counties most effectively work with your department?

"I do think our division of social services and our public health divisions have good working relationships with counties. But we've gone through a period of time in our department that a lot of decisions have been made internally around the table and that may not always turn out to be the best because some are not out in the real world doing the day-to-day operations. We have a number of missions and a number of goals we want to achieve in that department but there is not a single one of them we can achieve without the people out in the real world, working with the providers, people in the local health departments. As an agency here in Raleigh we can't accomplish anything. So when we are making decisions ... they need to be at the table and help make the right decisions.

"In mental health one of the things we wrestled with is we make decisions and then we change them and then we change them again. The providers out there go out of business because they can't deal with the cost of the constant changes. Most business people, if they know what the groundwork is, they can figure a way to make it work, but if the ground keeps shifting then you are never able to get to where you want to be. Open communication has got to be a part of it – if counties see ways that we can do things better then I need to know that."

How would you like counties to interact and communicate with your administration?

"As I build my leadership team I know the Association has a steering committee that deals with human service issues, and I know we have staff members that come to those meetings. ... If nothing is happening, you have no one there with decision-making responsibilities. I would really like to evaluate how we do that so we can have regular communications and make sure we have top-level people from the department participating.

"Over the next couple of months, as we develop a budget we are going to have to come up with a lot of ideas of how to do things differently. And being able to communicate and talk about those is a definite positive, and working through the Association committee structure is a good way to do that. There may be times when we work with an individual county, and we can do that, but as a policy-making process having regular communication can be helpful. That way you will know why we make certain decisions and we will also know what your issues are."

In light of the current economic climate, what can North Carolina counties expect to see from your department in terms of programs and initiatives? How can we collectively work together to minimize service cuts?

"I don't anticipate reducing eligibility or reducing services within Medicaid. I do anticipate trying to better manage certain services to make sure we are only providing services when appropriate. This is going to require perhaps an expansion of some services. We are going to see if we can develop some technology to help us monitor these things before the services are provided, rather than trying to figure out afterward whether they should have done it before. We are really trying to have that focus.

"We are trying to look at all the things we do that use a lot of money whether it be mental health, Medicaid or whatever and try to make sure that we have better control over what is being done and make sure it is done appropriately, rather than trying to chase after it after it has been done. That's where we have a problem and it has been an attitude in the department that if you have to go look at files and charts after the service and see if it is done right, then you've got to figure out how to get the money back in Medicaid. The minute we determine the service shouldn't have been done, within 60 days we are supposed to send the feds back their money, and it's too late. So, we are going to have to work on that.

"I really am focused on keeping development of our mental health system moving forward. I think it's critical there is a current feeling across the state that, yes, we can make progress and that's half the battle, having the confidence that we can. I'm going across the state and telling people what we are doing, and the reactions are very positive. Hopefully, even in this bad budget time, we are going to find ways to continue our progress there and redirect. I'm having a lot of conversations with the advocacy community and having conversations with the LMEs and the providers, asking what the barriers are, what do you see are the problems, how can we fix those things and continue forward? I'm just really optimistic about where mental health can go in the next couple of years unless budget numbers just totally mess things up. I'll do everything I can to make sure it doesn't.

"And again I'm going to try to get NCFAST on target. It's a challenge given the fact that they may have to use some or all of our reserve funds but I hope that I can keep that on target. The MMIS from Medicaid is going to be a big plus. The old system that we've had for years was designed to write checks. The new system is designed to write checks but even more important is designed to provide strong management information, which we have not had. I don't see us expanding any services, although I'm hopeful that I can find a way to pilot some services across the state where people have ideas in the health arena. I met with the Buncombe County manager and some others there, where they have idea for a pilot program in healthcare that I want to see if there is a way we can do, working through Medicaid to leverage some county dollars and get some federal dollars. And if we can find ways to pilot some specific things during this timeframe it will put us in a position to find what works and is beneficial and find ways to expand it. So we're looking for opportunities to move forward, looking for ways to deal with the budget that doesn't move us backward. Time will tell but I feel like we have opportunities to make that happen and we are working on it."

What steps could your administration take to strengthen and improve the existing relationship between your agency and county government in North Carolina?

"Making sure we have the communication is a big step."

What do you consider the greatest challenges facing your department?

"The budget obviously. Really building the management team that looks to the future. We have been for some time a reactive department that reacts to problems. I want to change that to where we are proactive department that tries to avoid the problems."

What do you hope to accomplish within your department?

"I hope whenever I leave that people will say that it is a different department – that we've really built strong management around Medicaid, which is our 600-pound gorilla; that we've torn down the silos in the different divisions and the department is working closely together; that people have confidence that the agency is doing its job where the Legislature does not feel a need to mandate or micromanage the department."

Contact DHHS Secretary Lanier Cansler, Deputy Secretary for Health Services Allen Feezor, or Deputy Secretary for Long-Term Care and Family Services Maria Foxx Spaulding at (919) 733-4534.