Six Essential Steps to Fix Medicaid

by Tom Campbell, executive producer and moderator of NC SPIN, September 26, 2013.

The Department of Health and Human Services clearly needs triage. While it serves no valuable purpose to list the litany of reasons why the department, especially our Medicaid program, is in crisis we can and must respond.

DHHS is the biggest, most complicated agency of state government, with programs that expend more dollars and affect more people than any other. It has been plagued by problems for years and we agree with Governor McCrory it needed new solutions. There’s no way the many problems could have been resolved in just eight months, but we are worse off today than when McCrory took office, partially because federal funding formulas have changed and many of the most experienced people have departed DHHS. Perhaps Secretary Wos is the wrong person to head DHHS. Her management style and results to date are not laudable, but this is Governor McCrory’s call to make.

In Medicaid reform we are essentially back at square one. Here are six steps we believe are essential to fixing it:

Acknowledge the problems

North Carolinians want to know our governor and our secretary know we have problems. We don’t expect perfection, but respect humility and honesty in our leaders. Step one in any recovery program is to admit the problem, so rather than ascribing blame or denying their existence we expect our leaders to acknowledge the problems and pledge to work cooperatively to solve them.

Set clear goals

The primary role of any executive is to set clearly defined goals and desired outcomes and then articulate them to all. Those goals obviously include an effective comprehensive care program for both physical and behavioral health that will result in predictable costs for Medicaid and our state budget. To achieve this will likely dictate a change from our current system of merely paying for services to paying for physical and behavioral health outcomes. That is the essence of managed care, but we deserve to know specific goals.

Challenge the stakeholders

North Carolina has smart and experienced healthcare professionals, but thus far they haven’t been very involved in Medicaid reform discussions. It is essential to include all the stakeholders, including care providers, such as doctors and hospitals, also insurance companies, pharmaceutical companies and most especially CCNC, an organization nationally recognized for managed care services to Medicaid clients. Further valuable resources would include Representative Nelson Dollar, former DHHS Secretary Lanier Cansler, regional public health professionals, legislators and, because the federal government has veto power and provides much of the funding, they must also be at the table. But ultimately, we have the brainpower and experience inside our own state to develop the plan best suited for North Carolina.

Governor McCrory should challenge these various sources to work together quickly to devise a Medicaid solution, one that can be implemented within the next 18 months. If they cannot agree, he can always fall back on the private managed care model he previously proposed.

Approve the plan

Once vetted and designed, Governor McCrory and the DHHS Secretary should approve, then thoroughly explain the plan to our state. Because Medicaid is such a critical and expensive service the governor must insist on total transparency in final design and implementation of that plan.

Monitor results

One of our biggest past failings is we didn’t get feedback soon enough from all the stakeholders, especially recipients and care providers. We must develop an extensive and effective feedback mechanism, then meticulously listen and measure results.

Be nimble and modify quickly as necessary

By it's very nature Medicaid is big and involves many working elements but we’ve been too slow to respond when changes were necessary. Once problems are identified we need to be nimble and quick to modify the plan to achieve our desired outcomes.

We must all work together to fix Medicaid. It is too important to get less than our best efforts because Medicaid directly or indirectly affects every citizen in our state. Governor McCrory needs to lead rather than dictate how this will be accomplished. His success and succession as governor may very well be determined by how well he manages this crisis.