Medicaid directors are uniquely situated to stimulate innovations in health policy and practice to enhance care, address complex health and social needs, manage costs, and, ultimately, improve health outcomes for the nearly one in four Americans currently enrolled in Medicaid. However, there are few formal opportunities for these state agency directors and their senior staff to strengthen the leadership skills and capacity to drive innovations toward these goals.

For more than a decade, Ed O’Neil, PhD, MPA, has provided leadership training for Medicaid directors participating in the Medicaid Leadership Institute — a national initiative led by CHCS and made possible by the Robert Wood Johnson Foundation — as well as training for senior managers participating in CHCS’ State Academies. CHCS recently spoke with Dr. O’Neil about why investing in Medicaid leaders is so critical, particularly with increased pressures to drive innovations in payment and delivery, control costs, and maintain coverage and quality of care.

Why is it important to invest in the leadership capacity of Medicaid directors and their staff?

A: Medicaid is a fantastic leverage point for change because it covers many individuals in every state across the country and it is a large part of state budgets. Yet, in most states, leadership development and capacity building is not a top priority. I was on the phone with a person on a Medicaid executive team recently who said, “We don’t spend any time, effort, or money on improving the skills of staff and we suffer because of that.” He had come from the private sector and pointed out that, “There are things that I was taught, reinforced, and encouraged to learn and use in that world that just don’t have a landing point in the Medicaid agency.” Investing in Medicaid leaders can help them take greater advantage of the opportunity Medicaid programs have to lead transformation in our health systems.

What advice do you give to Medicaid leadership about helping to develop their executive teams?

A: When you’re putting together an executive team, it needs to have a mission, goal, and defined role for the team and roles for the members. If you don’t provide these things, the team is going to meander and not be as efficient or effective as it could be. If it’s unclear what the team needs to work on or what the goal is, and the leaders don’t do a good job clarifying roles, then people may well be at odds and they are likely to turn on each other. This can create a whole other problem that takes away from actually getting the work done. Thus, it is critical to lead efficiently and in a way that keeps everyone involved and working in a productive and supportive fashion.

What is one of most common leadership pitfalls you have observed in your work with state Medicaid leaders? What advice do you give to avoid this pitfall?

A: It is important for the leaders within an agency to be clear about the values and the tone they want within their executive team. Such as, “I want people to be supportive; I want people to be open; I want people to push down decision making within their own sector.” It is essential for leadership to walk the walk. If they don’t want people to be on their devices during meetings, then leadership shouldn’t be on their devices. If they want people to be supportive of others, then they need to be supportive of others. Make sure you are embodying these leadership values in all of your interactions.

More and more state Medicaid programs are exploring opportunities for cross-agency collaboration and alignment. What are keys to making these collaborations work?

A: Three things are important in building effective collaborative relationships. First, be clear about what the Medicaid agency wants from the collaboration, what it can contribute to a partnership, who is interested internally, and how the goals of the collaboration relate to the agency’s strategic priorities. There’s nothing worse than engaging another entity when you’re not clear yourself about these important questions. Second, it is important to understand the other agency or department perspective. How are they approaching this initiative? How do they understand it and us? The best way to understand their point of view, of course, is to ask questions. Third, it is important to keep in mind that partnerships within state government are likely to be long-term undertakings. Build the relationship slowly around common ground so that it can be a lasting, solid, open, and transparent partnership.

What advice would you give to a new Medicaid director or future Medicaid leaders?

A: From the beginning, it is important to get your executive leadership team right. This includes the direction, the roles, the climate, and creating a safe place. The tendency is to immediately want to push to do things, initiate new programs, or draft new policies. Yet, spending initial time to create a strong leadership team foundation is essential to get things done. If you don’t have a strong team, then you might, by force of will or the energy of a new administration push stuff through, but things will start to fall apart.

It is also important – and most people don’t do enough of it – to build in multiple ways to continually get feedback as the director. It’s the hardest thing to get in the executive role, but continuously asking key questions provides critical information. These questions include: “How am I doing against these goals that everyone understands? How can it be improved? What are skills I need to develop?” It is important to keep open lines to get feedback. Without that, you won’t get vital information about correcting the path you’re taking.

What is one of the biggest adjustments new Medicaid leaders need to make?

A: People often work their way up from within the agency so their self-identification is more as a talented technical expert. Maybe they ran the policy shop or another functional unit extremely well. Because they did that successfully, they became Medicaid director and lead the organization. Now they are responsible for creating a vision for one of the largest departments in the state, but they still think of themselves as up one notch from when they were developing technical policy. Yet the answers for most of their leadership challenges are not found in the technical world, instead they require relationship building and strategic vision.

What motivated you to start developing the Leadership Tips series?

A: Leaders are busy people, especially individuals on Medicaid executive teams. The Leadership Tips fact sheets can help them address discrete problems efficiently. There are multiple entry points to improve leadership, but ideally, these simple tools offer something they can tuck away and remember the next time they need help with a day-to-day leadership challenge.