Oklahoma Medicaid Director Uses Behavioral Economics to Improve Diabetes Care and Builds the Medicaid Bench

    • April 26, 2011

The Problem. As director of the Oklahoma Medicaid program, Lynn Mitchell, MD, was responsible for ensuring that the state's 800,000 Medicaid beneficiaries received quality care. In doing this, she faced the challenges of meeting complex federal regulations and the negative views many constituents had of the Medicaid program. "Trying to change the public perception of the program and what it was able to accomplish was always an uphill battle, especially with the provider community, but also with the legislative community," she said.

Mitchell, who had previously been a faculty member at the University of Oklahoma College of Medicine, had received no formal training in how to manage a state Medicaid program and had little interaction with other Medicaid directors.

Fellowship offers support, ideas and skills. Mitchell was selected as a fellow in the inaugural class (2010) of the Robert Wood Johnson Foundation's (RWJF) Medicaid Leadership Institute. The institute is a fellowship program designed to help Medicaid directors enhance their leadership capacity through classroom training, access to national experts, networking with peers and a required practicum. See Progress Report.

Four multiday classroom sessions cover team building, strategic planning, networking and management. With just six fellows in her class, Mitchell had many opportunities to interact with other Medicaid directors. "Just being able every couple of months to sit down with your peers who are going through the exact same things you are and say, 'What are you doing?' and 'Do you think this is going to work?' was very helpful," said Mitchell.

For example, based on the Medicaid programs in Alabama and North Carolina, Oklahoma changed its delivery model to a patient-centered medical home. (A patient-centered medical home is team-based care led by a physician who provides continuous and coordinated care to maximize health outcomes.) Mitchell learned about the approaches used in Alabama and North Carolina through a fellow in her class. "Our patient-centered medical home program is not only better for the patient, but it also more effectively delivers care to them," said Mitchell.

Access to experts with innovative ideas about health care and Medicaid is another key benefit of the program. "The Medicaid Leadership Institute allows you to connect with people who are doing the heavy lifting around health care in the United States. It opens doors that you may not be able to open on your own," said Mitchell, "Instead of them telling us the way it's going to be, it allowed us to ask the questions. I was able to say, 'Here's the issue in Oklahoma' and get recommendations."

Among the experts were those who had actually written some of the language of the Affordable Care Act, the health care reform legislation that will expand Medicaid's scope dramatically. Mitchell and her team in Oklahoma were already having daily discussions about the legislation, but in a rapidly changing environment, it was hard to get good information. She found it helpful to get a hands-on interpretation of the reform.

Practicum: Reducing heart attack risk for beneficiaries with diabetes. Through a practicum that is required for all fellows, Mitchell introduced innovation to the Oklahoma Medicaid program. Her interest was in prevention and empowering Medicaid beneficiaries to take more responsibility for their health.

After learning how economics can influence the way people make decisions about health and health care, through Medicaid Leadership Institute faculty member Eldar Shafir, PhD, Mitchell believed she had found a strategy to reach Medicaid beneficiaries with diabetes. Shafir, the William Stewart Tod Professor of Psychology and Public Affairs at Princeton University, introduced Mitchell to ideas, the behavioral economics research consortium he was part of, and to Katherine Baicker, PhD, a professor of health economics at Harvard.

Baicker and staff from the Center for Health Care Strategies, the national program office for the Medicaid Leadership Institute, helped Mitchell and staff members at the Oklahoma Health Care Authority design and implement an outreach campaign targeted to adults with diabetes who had not had a statin prescription in the previous year. (Statins are cholesterol-lowering drugs that can reduce heart attack risk.) "They were right there saying, 'Here are people doing that kind of research; here are people you need to be talking to,' " recalled Mitchell.

In February 2010, the Oklahoma Medicaid program sent letters to about 2,300 beneficiaries encouraging them to talk to their primary care doctor about getting a statin. To test the value of incentives, beneficiaries received a plain letter; a plain letter and a $5 gift card; a colorful letter and sticky notes; or a colorful letter, a $5 gift card and sticky notes.

Although the results of the campaign still are being evaluated (as of February 2011), Mitchell noted that more beneficiaries were using statins after the campaign and physicians had been educated about their value. "I'm hopeful we moved the mark in people receiving more appropriate therapy for diabetes," she said.

Another benefit was that finance, policy and operations staff within the Oklahoma Health Care Authority worked with Mitchell on her practicum, enabling them to think about innovation and build new skills. "It was a way to enrich the working environment not only for myself but for some staff members at the Oklahoma Health Care Authority," she said, "The practicum introduced some of my staff to some health care leaders at Harvard and Princeton that we probably would not have crossed paths with."

A new position: Impacting public health. After serving as Medicaid director in Oklahoma for more than 10 years, in June 2010, Mitchell joined the Oklahoma State Department of Health, where she is chief medical officer and deputy commissioner of Prevention & Preparedness Services. In her new position, she is trying to "infuse public health and public health tenets" into the lives of Medicaid beneficiaries: "They should be married at the hip." Many Medicaid beneficiaries, for example, can benefit from the state health department's efforts to reduce obesity and smoking. Mitchell also is working on some joint projects with the Medicaid program.

RWJF and the Center for Health Care Strategies expected high turnover among the fellows since Medicaid directors are appointed by the governor and have an average of tenure of 24 months. But they also hoped the fellows would use what they learned in the Medicaid Leadership Institute in other publicly oriented health care settings—as Mitchell did.

"This is a leadership training program," said RWJF's special advisor for program development Nancy Barrand, the first program officer for the institute. "The most important thing the program can do is help ensure that what they take with them is a perspective of Medicaid as having incredible potential to be a leader in the health care field, and that whatever position they land in, they look for ways to continue to work with Medicaid in a positive way."

Mitchell now serves as a mentor to the Medicaid director in Illinois, a fellow in the Class of 2011.

RWJF Perspective. RWJF sees the Medicaid Leadership Institute as an opportunity to strengthen state Medicaid programs while providing a source of expertise to Foundation staff and other programs.

"Medicaid directors don't get a lot of training, and they're managing care for the sickest and neediest people in their states," said Deborah Bae, the current RWJF program officer for the MLI. "The Medicaid Leadership Institute gives the fellows the skills, space and time to learn about and pursue innovation and to think long term and strategically," said Barrand.

Barrand also emphasized the program's importance to RWJF's health care coverage strategy, since Medicaid is a substantial component of health care reform. Beyond that, it is relevant to many other programs across the Foundation, including those related to the criminal justice system, supportive housing and online communication for care providers. "Many programs depend on Medicaid or could leverage Medicaid to grow," she noted.