Caprice Knapp, former North Dakota Medicaid director, shares lessons she’s learned on how to maintain focus on key agency priorities amid a sea of constant evolving changes, needs, and requests.

Medicaid programs have always been busy, but with unprecedented enrollment, new and innovative state and federal initiatives, and daily operational needs, Medicaid leaders and their teams are busier than ever. A perennial challenge for Medicaid leaders is being inundated with competing priorities and struggling to sustain focus over the medium and long term. Medicaid leaders often need to balance being reactive to immediate issues — the “fires of the day”— while also keeping strategic priorities in focus.

Caprice Knapp is a Medicaid and health policy leader with more than two decades of experience working on Medicaid and CHIP in the private sector, state and federal government, and academia. As an associate professor in the Department of Health Outcomes and Policy at the University of Florida she conducted external quality review activities for the Medicaid and CHIP programs in Texas and Florida. Her public sector experience includes the Governor’s Office of State Planning and Budgeting in Colorado, the U.S. House of Representatives Energy and Commerce Committee as a Robert Wood Johnson Health Policy Fellow, North Dakota’s Medicaid director for three years, and she currently serves on the Congressional Budget Office’s Panel of Health Advisors. In her current professional role as a consultant, she works with states and health plans on quality and accreditation. This leadership profile reflects on Caprice’s experience balancing priorities and offers advice and strategies that she used to help the agency stay on track during her time as state Medicaid director.

A Shift in the Medicaid Policy Landscape

Caprice’s long and multi-state career working in and supporting Medicaid programs has allowed her leadership skills to evolve and provides her with historical context on the evolution of managing a Medicaid program. “Prior to the Affordable Care Act, there used to be a fairly predictable cadence,” Caprice explains, “where the legislative session would be busy, and Medicaid agencies would come out at the end with a list of items to implement.”  She contends that Medicaid expansion led to more awareness of the program among state leaders and a broader public understanding of the role that Medicaid can play in advancing health and well-being. “More people became excited about what Medicaid is and what Medicaid can do. The public wants eligible populations to be served and they want Medicaid programs to respond to those needs.”

With that excitement comes increased attention and new policy opportunities, which can lead to time and resource constraints for Medicaid agency staff. “We used to be able to shift resources to accommodate new policy directives,” she noted. “Now, there are so many competing priorities that we can’t make those same shifts.” As Medicaid grows — in size, scope, and public opinion — the ability to prioritize and focus among competing demands has become an increasingly critical leadership skill.

Accountable to Many Stakeholders and Multiple Priorities

Medicaid directors are responsive to their governor, state legislature, Medicaid members, providers, advocates, their staff, and federal officials at the Centers for Medicare & Medicaid Services (CMS), among others. These stakeholders and oversight entities may be more or less aligned on what Medicaid’s top priorities should be, depending on the state and circumstances. 

When Caprice stepped into her role as the North Dakota Medicaid director in 2019, she inherited 30 priorities, over 100 projects, more than 250 system change requests, and no clear map for prioritization. To get started, she focused on prioritizing what she was being asked to accomplish. She was also intentional about articulating her own priorities as Medicaid director. Caprice and her team identified four central priorities: (1) modularize their Medicaid Management Information System; (2) re-procure the managed care contract; (3) carve out pharmacy benefits; and (4) strengthen postpartum care. At the project level, Caprice and her leadership team were disciplined and focused on no more than 10 projects across these four priorities at a time. Everything else was in the queue and would move up when one of those 10 projects was completed. 

Across the agency, she gave staff permission to set things aside, gently reinforcing an expectation that if no progress had been made on a problem in five years, then it likely was not actually a priority. While some folks struggled to let things go, once they did the relief was often palpable. Intentionally moving non-priority projects to an inactive status meant that everyone was clear on what the true priorities were, and it became easier to assess and achieve real progress.

Just Say No(t Right Now)

The pandemic was an inflection point in managing priorities: “All of a sudden everyone shared one priority, something that hadn’t happened before.” In a few short months, Medicaid programs accomplished substantial policy changes that had not been accomplished in 15 years, such as 90-day prescription refills and expanding telemedicine. Although this required substantial focus and energy from Medicaid staff, an interesting benefit emerged from the single priority focus as well: Medicaid teams had greater understanding of their own capacity. By having the natural experiment of the pandemic, many teams learned how long and how many people it takes to do something “when no one is asking us for eight other things at the same time,” noted Caprice.

Coming out of the pandemic, Caprice’s team was better able to articulate the tradeoffs and/or expanded resource needs to shift priorities when asked for something. Caprice used this same framework for understanding staff retention. She saw the burnout and turnover creeping up in state government and Medicaid programs across the country and knew that pushing people too hard — particularly after two years of unprecedented demands — was untenable. Workforce retention had to stay top of mind amid the influx of new priorities post-pandemic. “I’m not going to risk losing our people,” Caprice found herself explaining to legislators and stakeholders, who often sympathized with the challenge and appreciated her perspective.

Staying Focused

But what happens when there’s a new issue du jour? Or when a well-intended legislator comes back from a national conference with an innovative approach that Medicaid “simply must try”? Sometimes it’s uncomfortable, Caprice acknowledges. In these moments she finds herself saying, “Here’s what we agreed are the top priorities. Do you want us to switch, and if so, what should fall off?”  Often, that reminder is enough to pivot back to the original priorities; but occasionally, priorities will shift, and something will fall off to make room for something new. Caprice also developed processes to handle single member issue escalations. “We needed established channels for triaging and responding to member issues while still maintaining strategic direction.”

Staying focused is a tactical strategy as well. “I sent a weekly email newsletter to staff that included an update on where we were on our four central priorities,” noted Caprice. “Those four priorities were at the top of the agenda in every public meeting.” This repetition reinforces a north star that everyone inside and outside the agency is aware of and can point to.

Leadership Takeaways

Maintaining focus on agency priorities can be a challenge when they are in constant flux. Caprice’s experiences and advice highlight the following:

• Know your bosses and know what they want. But know what you want, too.
• Distill, distill, distill. Whittle a list of priorities that you and your team truly believe is manageable.
• Be upfront about resource constraints. Clearly articulate tradeoffs and what it would take to execute a new priority and empower your team to be realistic about their own capacity.
• Employ tools and tactics to maintain your focus. Be intentional about making the decisions to adjust priorities when the situation calls for it.

Additional Resources

For additional resources that can support you in maintaining focus on your priorities, check out:

• When and How to Say “No”
• Influencing Up: A Big Challenge
• Building and Using Executive Teams