Health Policy - New York State

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December 10, 2004

Comments

John

Paul

Where you talked about "vertically aligned bureaucratic systems" you talked about agencies working at cross-purposes I have to agree that this happens a lot, but I don't expect those systems to be able to fix the problems themselves. It's a classic organizational problem and solving it is a function of leadership. If elected officials (or any other leaders) do not actively design their organizations to allow and encourage effective functioning across those vertical systems, they won't. Most at the top of hierarchies not only don't do it, they inadvertantly, but actively punish such behaviors. It happens everywhere; not just in government.

If leadership demands and designs systems for serving the customer well rather than internal organizational structures, then things change. Seems to me that the big challenge here is for you, your colleagues and counterparts to think of clients of county services (such as Medicaid clients) as customers. Hard to do, isn't it?

Mind you, I'm not suggesting that serving our customers well necessarily means serving them more. It means figuring out what works best, doing it, and treating the customers well. In this realm, we generally don't.

John

Paul

You said that you would phase-out of the county share of Medicaid. (You might want to take a look at some of the proposals listed on this site under the Medicaid archive). Simultaneously, you would offer counties opt-out provisions for those services which are not offered by a majority of states. I've two questions:

1. If the county share is going to be phased out, why should we allow counties any role in reducing the services that Medicaid offers?

2. In my editor's note, I listed a couple of the optional services that New York's Medicaid program covers. Which, if any, of those would you drop?

JWR

Paul DiGiovanni

In response to the clients-as-customers post:

I am actually quite pleased by the initial response of many who work within the system. They feel the frustration themselves. And the idea that there are legislators willing to support them in trying to do things differently, it seems to me, has great appeal. There was, I think, a knee-jerk reaction to the new legislators at the start of our term back in January that we were just going to rail about the cost of everything, and attempt to cut, cut, cut. I don't think I perceived how strong this sense was within the County Office Building, as it was certainly not my intention to cut blindly. I think there was a lot of defensiveness, because any attempt to change something is, in truth, an implicit statement that there is something wrong with the current way of doing things. On the other hand, of what can't that be said? Are there any perfect systems? Of course not.

I am not necessarily interested in breaking down the current structure of the county government as I am in refocusing how government goes about achieving its ends. So, while we may still have separate departments of Human Services, Health, and a Probation Division, my goal is to get them to work together, to work more efficiently, to make decisions that affect each other with the full input of all who are affected by the decisions made, etc. We might need to add to the existing structure (e.g., create a committee that consists of heads of various departments, some legislators, and perhaps some other interested parties, such as the Board of Health) in order to create a mechanism for doing things this way, but it doesn't have to supplant what we have now, I don't think (subject to review based on my experience!).

I don't know if I have mentioned this link elsewhere, but if not, the study that can be downloaded here: http://www.cgr.org/Articles/?id=136
served as an affirmation that the ideas that were swirling in my mind were not only not crazy, but were precisely what was being recommended by a consultant to a NY county government. So I am beginning the process of introducing this approach to Cortland. It is very early, and I probably won't be able to give you useful feedback on outcomes for quite a while, but I will be happy to give you updates on the progress we make, the obstacles we encounter, etc. There is a lot more I want to say, but perhaps that's better handled as a different article/posting.

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