Welcome, you have a big job ahead of you. Connecticut’s Department of Social Services (DSS) is a huge agency, spending $8.4 billion this year for programs that impact many lives. As a healthcare advocate who has spent decades trying to move your agency and your predecessors, with mixed results, you have a difficult job. Luckily there are hundreds of stakeholders, including advocates, outside the agency who want you to succeed. For what it’s worth, here is my advice.
Your biggest challenge is building trust – with your clients, communities, their representatives in the General Assembly, with healthcare and other service providers, and taxpayers. Mistrust is pervasive and your agency has not escaped it. You will encounter a lot of skepticism and resistance; none of which is your fault. But keep trying, we will come around.
Be careful making promises, but when you do, keep your word. Take everyone’s input; you never know where the good ideas, or the red flags, will come from. Your predecessor set up regular meetings with advocates to hear what we were seeing, what kept us up at night. He didn’t wait for us to call him, or worse for negative press, proposed legislation, demand letters from lawyers, or just the slow drip, drip, drip of people giving up on the programs.
Always be guided by the best interests of clients and taxpayers – full stop. When you have to do hard things, and you will, remind us all of that. If you stay true to that fundamental, you will have a lot of help from advocates, providers and others. Our motivation is the same as yours. We volunteer on committees, councils and lots of working groups. You couldn’t buy these resources at any price. For example, advocates fought for over a decade to rid Medicaid of capitated managed care plans. Since firing the insurers seven years ago, access to quality care continues to grow and the state is saving almost a billion dollars this year. Connecticut is now a national model in turning around Medicaid spending and quality erosion. We helped the state develop the PCMH Plus shared savings program, which had a disappointing and costly first year, so we are currently working with your agency and consultants diving into deep weeds to fix it.
Broad engagement in development makes implementation success far more likely. Do not waste money on high-priced consultants who don’t know Connecticut. Too often they cut-and-paste from a different state or the latest shiny new thing from think tanks, and then leave us to clean up the mess and start over.
Don’t try to fix everything at once but be persistent. Give us the big picture but take reform one step at a time. Rushing into big changes invites disaster. Connecticut’s policy landscape is littered with big vision reforms that fell flat. We need sustained, meaningful forward movement. But don’t expect us to fall for pointless “baby steps” that look like progress but aren’t. While you are checking boxes, the problems get worse.
There will be lots of barriers in moving forward but don’t take no for an answer. Some excuses you will hear—we don’t have money for that, no one will sign up, we don’t have a code to pay for it, the system isn’t set up for that, quality can’t be measured, and my favorite, no one will do it unless they are paid more. None of them is an acceptable excuse to do nothing. Dig into the weeds and find a way. You will find a lot of help inside and outside the agency, as long as the goal is improving the lives of your clients and responsible stewardship of tax dollars.
Admit when you’re wrong and fix it. Our state’s Medicaid program wasted billions of tax dollars and years of poor health outcomes for clients while your predecessors and their staff refused to see the overwhelming evidence that capitated managed care was failing. Despite overwhelming evidence, they remained stuck (some are still trying to return to that failed model). Don’t fall into that trap.
Data, data, data. Collect it, share it, analyze it, and follow it. Hear what it’s saying and act on it without fear or favor. Understand the limitations of data, what gets measured and what doesn’t, what we have evidence for and what we don’t, but never let that be a reason to do nothing. We will never have enough data, but there are always signs. Your best defense to the naysayers is good data, carefully and transparently analyzed, that leads to the right option. Show us your math and listen to ours, we may see something you missed.
Accountability is hard. You will have to balance holding providers accountable for quality and efficiency with the fact that we can’t lose anyone from this program. Medicaid is too important to lose anyone. You have to give everyone a reason, and the tools, to improve. Stay constructive and rely on the data.
I am an advocate, so there is also a list of policy dos and don’ts. Many I covered last year in my advice to your boss. Do not return to the failed capitated managed care model or the even worse provider risk payment models. Asset tests for Medicare Shared Savings is an administrative nightmare, will be costly, and will crowd-out more important things your staff needs to be doing. Despite progress by your predecessor, serious administrative problems persist especially in enrollment, renewals, customer service and you are being sued over the transportation mess.
It’s a big job but there is an army of people that want to help. In his first week or two, Commissioner Bremby was presented with results of a study outlining big problems in his agency’s operations and real-world recommendations to fix the problems that are working in other states. He listened carefully, asked great questions and then got to work. DSS has now implemented almost all the recommendations and the program is better for it. But Connecticut thoughtleaders have offered you a wealth of advice. You don’t have to do this the hard way.
EDITOR’S NOTE: Gov. Ned Lamont has yet to nominate someone to the position. DSS Commissioner Roderick Bremby has agreed to stay on until Lamont announces a replacement.
Ellen Andrews, PhD, is the executive director of the CT Health Policy Project. Follow her on Twitter @CTHealthNotes.
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