Rhode Island Medicaid provides access to healthcare for nearly 350,000 members. The program covers one-third of Rhode Island residents and over 50% of the state’s children with a budget of nearly $3B. Medicaid provides an essential social safety net from cradle to grave, covering an outsized share of births, pediatric care, behavioral health, and long-term care for the elderly. Pulse writer Jeremy Rubel sat down with former Medicaid Director Ben Shaffer (WG ’14).

The Pulse: Can you give us an overview of your career and what inspired you to join the state government of Rhode Island?

Ben Shaffer: I joined the state government in March 2016 as Director of Performance Management in the Office of Management and Budget. I was and still am very motivated by helping to make the government work better. Prior to Rhode Island, I completed a joint degree at Wharton and the Harvard Kennedy School. I am interested in learning about how business and government can work together and learn from each other. Immediately after graduate school, I worked at BCG for 6 months. A colleague at BCG was leaving to join Governor Gina Raimondo’s administration and she recruited me to join.

I stayed for five and a half years because I kept saying yes to new challenges. I continued to see the chance to make a big impact in state government.  The project that put me on a health and human services trajectory was the turnaround of a failing IT project that integrated eligibility for Medicaid, SNAP, childcare and Temporary Assistance for Needy Families (TANF). Fixing this IT system meant low-income people could access health care and food. From there, I joined the Executive Office of Health and Human Services and became Medicaid Director in February 2020.

The Pulse: Why are you leaving your role as Medicaid Director and what are you planning to do next?

Ben Shaffer: I enjoyed my time in RI. State cabinet-level jobs are intense, and Covid made it even more intense. We accomplished a lot, but I found that it was time to think about next steps. In February, I am headed back to BCG, joining their health care and public sector practices.

The Pulse: What is your proudest accomplishment as Medicaid Director?

Ben Shaffer: Starting in Fall 2020, we began a year-long redesign and re-procurement process for our managed care organization (MCO) contracts. These are very large contracts of over $1B caring for over 80% of members. The contracts are critical to the agency’s success, but we hadn’t updated some core components of the contract since the late 1990s. Today, Medicaid is trying to accomplish so much more and covers many more people. We now have value-based payments, investments in social determinants of health (SDOH), and accountable care organizations (ACOs). We conducted an extensive stakeholder engagement process and formally released the RFP in November 2021. I think the document significantly advances the agency’s strategic goals and I am excited for the team to carry on this work.

The Pulse: Why do most state Medicaid agencies contract with managed care organizations (MCOs) rather than directly paying for members’ health care? What value do MCOs provide to Rhode Island Medicaid and its members?

Ben Shaffer: There are immediate practical considerations and complex, fundamental considerations. Practically, managed care increases access and improves provider networks, especially specialty provider networks. For their managed Medicaid members, private payers may mirror the networks they have built for commercial or other lines of business. Also, MCOs can more efficiently administer the program because of their scale. When contracted, the MCO is responsible for billing, provider enrollment, and member engagement. If the state didn’t contract with managed care, we would need to build and pay for these functions directly. 

The more fundamental answer is that MCOs are meant to provide care management services that are essential to members with complex or behavioral health needs. The state could have a fee-for-service (FFS) system and separately contract with care management organizations. But this would be more complex and create a more disjointed experience for members. States also see savings from MCOs because good care management leads to better health outcomes which lead to less health care spending.  That’s the virtuous cycle we aim for.

The Pulse: Because Medicaid agencies rely so heavily on MCOs, it’s essential to hold them to a high standard. How do you hold vendors accountable?

Ben Shaffer: We invest in a contract management process that looks like a monthly business review. Over time, starting before I was Director, we developed an organizational muscle memory. We set goals and review data with our partners regularly. It is not terribly innovative – these are simple actions – but you need to invest in relationships to make the partnerships with vendors effective. And they work.

Successful contract management requires investment in high quality state staff. I regularly had meetings with the governor’s office and legislative branch to make the case for competitive salaries for contract manager jobs. You need to pay a fair rate to recruit and retain the talent required to manage billion-dollar contracts. 

A lot of government service is about finding the right levers to pull. Folks sometimes wait around for a new law or more money; these are long term fixes you can certainly try to influence but are ultimately outside your control. Alternatively, effective contract management of the MCO is a powerful lever. If you read the contract, the state already has a lot of power in contracts with MCOs, but just because the rights are on paper doesn’t mean the state is able to execute. I try to get my teams excited about contract management because you can make a big difference if you’re dedicated and persistent. 

I think following the stresses of COVID-19 on the health system, the value delivered by MCOs and the state’s ability to manage those contracts will continue to receive critical attention. Certainly it was a topic discussed by the Rhode Island State Legislature.

The Pulse: Rhode Island Medicaid has an accountable care organization (ACO) program, first implemented in 2017. ACOs align with MCOs to take responsibility for the total cost of care for a patient and have greater flexibility to invest in a member’s social needs, like food or housing. Reflecting on the first four years of the program, what impact are ACOs making? Where is the program headed next?

Ben Shaffer: Our thesis is that to deliver high quality care, care needs to be as close as possible to the patient and address members’ social determinants of health (SDOH).  For example, treating chronic conditions requires primary care, case management and attending to social needs. ACOs have greater flexibility to invest in SDOH than traditional fee-for-service medicine. ACOs receive monthly payments for each member in their attributed population and are held responsible for the population’s outcomes. This incentivizes ACOs to invest in the population’s health, treating members’ SDOH needs directly, rather than waiting for patients to visit the doctor’s office as they would under a FFS model. And in the early data we see that ACOs have been able to reduce total cost of care without sacrificing quality.

The ACO program includes additional tools that amplify our focus on SDOH. After an RFP process, the State of RI awarded a contract to a community resource platform, Unite Us, to help ACOs connect with community-based organizations. Just like a primary care provider can make a referral to a specialist, an ACO can make a referral to a food bank or housing support organization.

Going forward, our policy encourages ACOs to develop more specialized care management models. We are creating a playbook in our managed care procurement that distinguishes simple care coordination and complex case management for someone with multiple chronic conditions. In particular, I expect more specialized care models for behavioral health patients.  This is an area of real challenge across the country and one in which we need to foster innovation.

The Pulse: You became Medicaid Director February 2020 just as the pandemic was surging in the US. Can you walk us through those first few months? What did RI Medicaid do to keep its members safe and support the state’s healthcare system?

Ben Shaffer: We focused on access to health care for our members, first and foremost.  And that meant paying close attention to provider solvency.  That was our role as the Medicaid agency in the whole-of-government response managed by the RI Department of Health and the Governor’s office.

In the first months of the pandemic, we saw 30-50% drops in healthcare utilization by members in our state. This was the policy intention – we wanted people to stay at home. But this had a major impact on member health and provider revenue. We had a responsibility to make sure providers stayed in business, so they would be able to continue to care for our members in the long term.  We also had the responsibility to make sure funding was going to the workforce and to ultimately improve patient care, particularly in the long-term care sector that was hit so hard by the early waves of COVID-19.

All told, we implemented more than 16 provider relief programs. We used the utilization data and our understanding of providers’ finances to target the flow of resources. We also implemented work force supports. For example, we made sure that anyone going to work in a congregate care setting was making at least $15/hour. To do this, we created a new program to grant money to providers but imposed stringent requirements to make sure the money was passed on to these workers.  And we did all this very quickly, by May of 2020, to respond to the initial phase of the public health emergency. 

As the pandemic continued, we worked to ensure that our members were getting the care they needed. For example, we worked closely with a group of pediatricians to promote vaccinations. Medicaid is a very children-focused program, covering 55% of kids in Rhode Island. One of our goals [during the pandemic] was to avoid a reduction in immunization rates. Vaccinations are critical because they prevent illness but also because an immunization implies that a kid had a visit with their pediatrician. At a well visit appointment, the pediatrician can monitor the child for developmental delays and other issues. We created a pay-for-performance program that incentivized pediatricians to conduct well-child visits and provide immunizations to their patient panel. Remarkably, we saw a higher well-child visit rate for participating practices in 2020 than in 2019. Value based payments are powerful; they can even work in the middle of a pandemic. 

The Pulse: The theme of our conference is “A Fair Shot at Health.” Medicaid programs play an essential role in advancing health equity given its mission to serve low-income members. What metrics do you use to measure the agency’s progress on health equity? 

Ben Shaffer: There is no perfect set of real-time data to measure health equity. Medicaid programs often don’t know the race, ethnicity, or language of all their members because they are not required to provide that information when they enroll, especially if they are dually-eligible for programs like SNAP. And the traditional HEDIS measures are reported with a 12-18-month lag that makes it difficult to use those metrics for the kind of MCO active contract management I talked about. So, our job while we work on getting better race, ethnicity, and language (REL) data is not to wait, but to find proxy data measures that are leading indicators. 

We often look to measures we know that if we impact, then we will have a disproportionately positive return on health equity. For example, for core medical quality measures like breast cancer screening, post-partum outcomes and diabetes management, we put extra emphasis on improvement because we know that if we improve in these areas, we will make progress on health equity.

We want to make sure health equity is a core part of our overall quality strategy. We don’t want health equity to be sitting off to one side. In our managed care contracting, we made sure meaningful health equity measures were part of our value-based payment strategy and quality-withholds for MCOs.

The Pulse: During the pandemic, Rhode Island hired management consulting firms like BCG and McKinsey to support the state’s Covid response. What value do management consultants provide when working for state governments?

Ben Shaffer: During Covid, the management consultants rapidly provided extra talent and labor. I guess I should speak for myself, but I can’t emphasize enough how much our incredibly lean and underinvested in public health infrastructure was overwhelmed. For decades, our public health infrastructure has not received sufficient investment. Consulting firms were able to provide immediate human capital to help us develop a strategy to solve novel problems, assemble data against that strategy, and execute on practical operational challenges.  For example, consultants helped us launch the provider relief programs I mentioned.  It is hard to launch 16 programs within 3-6 months and to do that you need extra help.

On a more ongoing basis, consulting firms provide a perspective on the market. Organizations do a better job when they broaden their horizons. Rhode Island is a small state. We don’t have the staff to track what’s going with every Medicaid trend. I’ve seen consulting firms be able to bring in real expertise.

As an ex-consultant, a government official who has hired consultants, and someone who plans to return to consulting, I know that there is both good consulting work and bad consulting work. It was my job as the client to tell the difference, manage appropriately, and contract appropriately. I recognize that it is possible for organizations to become too dependent on consultants. State governments are successful with consultants when the problem is well defined, and you are asking for the answer. A project should be we need a strategy for X, we need a policy for Y, or we need to implement programs for Z.  Or to build capacity within the organization to do that itself.

Doing new things is hard for any organization, and especially for short-staffed state governments. All our program administrators are focused on managing their programs. So, if you want to develop something new, you need to invest in human capital. Often, for a short-term project, it makes more sense to hire a consulting firm than a new FTE.

The Pulse: What advice do you have to students or early career professionals who are considering a career in public service?

Ben Shaffer: I found my time to be incredibly rewarding. But I am direct with students that the public sector pays less than the private sector; if the public sector is something you are interested in, you need to be mindful about your personal and family situation. If public service is something you want to do with your career, it’s important to plan for how to avoid feeling locked into a certain salary level. The pay scale is a barrier for many MBA students, and that’s why I am upfront with people I talk to about that.  

Those who choose a job in government will make a big impact and learn fast. Rhode Island Medicaid covers nearly 350,000 members with a $3B budget. We have an extremely lean staff. My recruiting pitch was that we give talented people big opportunities earlier in their career. If you want to manage people, to develop a policy, or implement a program, we say ‘go for it’. We try to not be a staid bureaucracy. MBAs are in the minority and you will get to learn from and work with social workers, data scientists, and PhDs. For those who choose this path, you can do a lot of good in state government and feel that every single day.

Interviewed by Jeremy Rubel, December 2021.