WA: Interview with MaryAnne Lindeblad, Director of Medicaid – Part 1

MaryAnne Lindeblad is the Director of Medicaid at the Washington StateMA Lindeblad Health Care Authority, and is at the center of system reform in Washington State.

This interview was conducted over about 30 minutes.  Part 2 of this interview will be posted Dec 30..


Q:  So, how is it going?  How is Medicaid expansion going and life in the middle of the health policy whirlwind going as Director of Medicaid?

A:  All things considered, I think things are going well.  People are getting enrolled. It’s exciting to see the number of dual eligibles coming through the door.  We have our new contracts with our plan partners for January 2014 going out.

We’re continuing to improve how services are delivered for the folks we serve.  We are addressing a number of the concerns that came out of our procurement in 2012.  I think we are strengthening the contracts and the relationships with the managed care plans.  We have now 80% of the members that we serve in a managed care plan today, and we’re certainly improving the quality of the access and the quality of the care for the members that we serve.

So I really feel like we’re on a good trajectory.  It’s a very exciting time. We’re ready for it, and I’m anxious for January 1st but we’re ready for it.

Q:  How much of your time is spent today thinking about implementing Medicaid expansion versus how much of your time do you spend about what’s coming next with the Innovation Plan and what’s coming next in Medicaid.  How does that break down?

A:  I would say right now about 75% of my time is thinking about expansion and moving forward but in that context the excitement about the Innovation conversation and moving the delivery system is about 25% of my time.  Within a year I hope those are switched or maybe 6 months.  Because it’s really about what we want the future to look like, and how do we take the opportunities to look at better integration, better financial alignment with the provider community, doing more innovative payment reform, and that’s really where I want to be spending my time.

I think we’re going through a transition time right now with the expansion, so I need to focus on the expansion to make sure we’re moving forward and getting the value out of our delivery system.

But, we need to acknowledge that there are changes that will happen over time.  I think the whole integration discussion is an important discussion right now, and what we want that future to look like around what behavioral health services will look like.

The demographics of the Medicaid population are really going to change over the next couple of years, and I think the delivery system needs to be able to accommodate that demographic shift.

Q:  Give us a view from the inside about the policy development related to integration.  I know over the last 6 months there was some difference of opinion between the HCA and DSHS, and a difference in the reasons they were driven to this question.  But, how did that conversation take shape over the last six months that brought us to this place today?

A:  I think we all agreed on what the end point needs to look like.  It’s really about the timing and the how.

So how do you get to a delivery system that provides a fully integrated product, and what does that delivery system look like?  Does it have to be through the traditional way we look at the world today?

I think we have an opportunity to look at different alignment within communities.  The role of counties certainly could be different.  The whole conversation in the SIM grant around Accountable Communities of Health:  what would that look like and what does that mean?

I think our goals are the same:  we really want to move toward a fully integrated delivery system.  But we know – at least I believe – that will look different than what the delivery system actually looks like today.

The whole regional conversation will be different for folks.  The kind of partnerships that need to happen around integration within a community will be different.   How do we draw in providers differently than we do today?  The role of county government is so important and that role needs to be strong.  I think what we’re talking about could even strengthen that from a quality and oversight perspective.

We agree on the end point, and I think even now we agree on how to get there.  But I think some of the conversations over the last 6 months really needed to happen for the agencies to get out on the table from a direction perspective what’s possible.  Again that community engagement that’s so important to this.

I think sometimes we forget that really all health care is local, and how do we drive decision making within a local infrastructure that supports the intentions and the goals that we have moving forward.

It’s kind of a complicated issue but I do think that this integration discussion has really been great in terms of really developing our thinking about what we want the future to look like for the folks we serve.

Q:  I’m struck by how unified the agencies are today compared to six months ago, and generally how supportive agency leadership has been of the role the Governor has played and his engagement on this question of integration.  Is that an accurate understanding?

A:  Absolutely that’s accurate.  His leadership has been key in moving this forward.

I think his was an important acknowledgement that how services are delivered and what the end game is needs to be about how we best serve the clients who need these services, and do it in a way that provides the best opportunity to help deliver and manage services for a high risk population, really on the behavioral health side.

When we see things like that many folks with behavioral health issues live 25 years fewer than others, and that it’s mostly because of physical health issues, the data is very compelling that we need to move to a more integrated product.

But that really does change the world for the current delivery system.  So what does that mean, and how do we address and keep the things the system does well.  And we don’t lose, and I think that’s a really important thing about this.

Any system we move to in the future needs to be about improving rather than losing ground in any way.

I think this model, the dates that we’ve set out, the time we’ve given to do this, the governor’s position on this, it all really creates a framework for us that allows us to build a delivery system that really builds off of the strength of our current delivery system to build a better integrated product for the people we serve.

That has to be the bottom line:  it really has to be about the people that we serve.