Posted: 19 Nov. 2019 4 min. read

Medicaid agencies should try to avoid spinning too many plates

By Jim Hardy, specialist executive, State Health Transformation Services, Deloitte Consulting LLP

I might be dating myself here, but I can remember watching the Ed Sullivan show as a kid on Sunday nights. Aside from musical acts like the Doors and the Beatles, one of my favorite performers was a plate-spinner named Erich Brenn. It was mesmerizing to watch him frenetically race around the stage…using physics and timing to stay a step ahead of gravity. Brenn’s skill at keeping multiple bowls and dinner plates spinning on top of poles and on tables became synonymous with multi-tasking. He probably would have been an exceptional Medicaid director.

Consider all of the plates that Medicaid directors are spinning today: Value-based purchasing, chronic-disease management, dual-eligible integration, patient-centered medical homes, cost-containment programs for prescription drugs, social determinants of health, and community engagement initiatives. While some of these new initiatives might improve patient outcomes and member experience, they also can pull resources and focus from existing programs. But deciding not to take on a new project might be tougher than starting one—particularly if there is pressure from stakeholders, the legislature, or the governor’s office.

When I was Medicaid director in Pennsylvania, I limited the number of strategic initiatives we took on to no more than three at any given time. I can remember having a challenging budget year and we were under tremendous pressure to cut costs. We stopped working on small projects and chose three large initiatives that would have the biggest impact. We focused our resources on implementing our preferred drug list, launched an enhanced primary care management program, and instituted a hospital quality program. Resisting the temptation to take on other projects was sometimes difficult, but staying narrowly focused helped us achieve our goals. I recommend taking this approach to all health care leaders who are constantly spinning plates or juggling investment decisions.

Four recommendations Medicaid leaders should consider

Most state Medicaid agencies are perpetually trying to come up with strategies to make their programs run more effectively. At the same time, they are typically dealing with constant budget pressure, and a desire to create more value for beneficiaries and taxpayers. But managing multiple programs, and regularly evaluating them, can be daunting, particularly if new initiatives are coming on line. Consider these four strategies:

  1. Don’t overload the plate: Medicaid directors typically pay close attention to what’s going on in neighboring states. They share ideas and often learn from each other. A new program in one state, for example, might prompt another state to follow. But that can lead to challenges if the staff isn’t prepared to take on something new, or if existing initiatives are still maturing and have not yet been fully evaluated. For example, some Medicaid offices are devoting more resources to social determinants of health, while others are implementing value-based purchasing (VBP) efforts. Some offices are doing both. The Medicaid director should evaluate the success of all existing projects before loading up the plates with something new. As much as the Medicaid director might want to keep up with the latest trends, it can be difficult to do everything and still succeed.
  2. Evaluate the success of each program: Medicaid agencies that conduct multiple projects in parallel will likely need strong analytics to isolate the variables and evaluate the effectiveness of each initiative. They will also need to evaluate the return on investment for each program. This could require new investments in infrastructure, technology, and analytics support.
  3. Put a few plates down: It can be exceptionally difficult to end a program…even one that hasn’t succeeded. It is often easier to adopt new programs than to shutter existing ones, particularly if investments have been made or if it was launched in response to the legislature or governor’s office. When a program doesn’t achieve expected results, the Medicaid agency either needs to end it or double down to help it succeed. This is easier said than done: some stakeholders often become invested in the status quo so they might push back against plans to shelve an initiative.
  4. Evaluate resources and talent: Before moving on to a new project, Medicaid directors should determine if their existing staff has the necessary skills and experience to start new programs even if they do a good job managing existing ones. Moving from a fee-for-service (FFS) model to managed care or committing to VBP, for example, requires different skillsets. Medicaid offices should determine whether that expertise needs to be recruited or if it can be developed internally. 

Taking on additional initiatives is nothing new in Medicaid, but it seems like many Medicaid directors have more plates spinning than ever. For any health care stakeholder, too many plates can create a backlog and a strain on the agency as staff members run from one initiative to the next to make sure nothing drops. Before picking up the next plate to spin, Medicaid directors should consider taking a breath and a step back to assess existing programs.


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Meet Jim Hardy

Jim Hardy

Jim Hardy

Specialist Leader | Life Sciences & Health Care

Jim is Deloitte Consulting LLP’s Medicaid Advisory Services lead. Previously Pennsylvania’s Medicaid director, he has more than 20 years of Medicaid, health policy, reimbursement and rate development experience. Recently, Jim assisted in developing a state Medicaid care management strategy and long-term care reform strategy; assisted states with coverage initiatives; and led a hospital payment reform initiative for quality incentives and to reduce payment for avoidable re-admissions.