Cuts for Medicaid are a feature of the current administration’s efforts to reduce the budget deficit based on the rationale that spending for health entitlement programs will stretch the federal budget beyond its limits. This is because increased longevity is raising the number of the aged population while a rise in the poor is increasing the number of those eligible (Abramsky, 2011). Budget cuts mean that some services would need to go. As a manager of a county clinic servicing Medicaid clients, it is my job to make the decisions as to which services would be eliminated. Optimal decisions must be based on evidence and the informed decisions toolbox (IDT) is helpful in this effort.
The first step is to frame the management question which addresses the intervention, outcome, setting, time frame and population (Rundall, 2007). Eliminating services is the intervention and the setting is a county clinic. Since the decision is based on the percentage of budget cut, it is reasonable to say that the time frame is until the next round of tax cuts take place. To remain a relevant safety net for the public’s health, Medicaid should cover as much of the current and projected eligible population’s needs as possible but with a priority for the poorest segment who have the least capacity for out-of-pocket spending. The outcome should then be cost-effectiveness within state health reform mandates while generating the best possible health outcomes for county population. Therefore, the management question would be, “What services should be eliminated from the county Medicaid program but which will have the least impact on the county population’s health and in conformity to state policies within the duration of the 15% budget cut?”
The key to making the best decisions is to have adequate and reliable information. The second step of the IDT is to find sources of information (Rundall, 2007). Based on the management question, areas of research are: the Medicaid programs currently offered, existing state health reforms on Medicaid use, the current demographic, economic and health characteristics of the population being served, trends concerning these characteristics, the ranking of Medicaid services according to demand, projections in demand, and determining the possible health impact of eliminating each of the services. Information on Medicaid programs and related state policies can be found in state department of health websites. Demographic, economic, health and Medicaid use data can also be obtained from government health websites. Alternatively, a survey of the county population along with a clinical audit can be done to determine unique characteristics, trends and demand. Existing primary research and the expert opinion can be used to generate projections of both demand and service elimination impact.
After obtaining relevant information based on data needs dictated by the management question, the third step is to assess information accuracy using the standards of the organization (Rundall, 2007). In general, accuracy depends on the research method used to produce the information. For example, a descriptive study on the impact of the elimination of Medicaid services using information either from prior research or expert opinion is less accurate compared to a primary research actually documenting a relationship between service elimination and its impact on a given population through direct causation or correlation. In addition, the date the study is done is important. Considering that the context of the decision making is the current health care reforms, more recent researches are more accurate than older ones.
The fourth step is assessing whether the information is applicable in the management context (Rundall, 2007). Information sources should be selected on the basis of their fit to the county clinic’s situation. Case studies done on health care reforms and health entitlement budget cuts at the community or state levels in the U.S. have a higher applicability than studies done in other countries. For example, the research by Lowe et al. (2008) showing that Medicaid budget cuts in Oregon, which led to stricter imposition of premiums coupled with a reduction in the range of services covered, resulted in a sharp and steady rise in emergency department visits mainly by the uninsured is more useful than a similar study conducted in China which has a different health care system. Research in the primary care setting is also nearer to the decision-making context in question compared to hospital settings.
Closely related to the preceding step is the assessment of evidence actionability, the fifth step (Rundall, 2007). Essentially, this means determining if the study results provide practical information which can be readily used when taking a course of action. For the management question, studies should provide practical indicators for Medicaid service reduction outcomes among others. Considering the above study by Lowe et al., it merely documented the effect of Medicaid budget cuts and services elimination in general on ED visits but has not specified the implication of this finding on health so that the number of ED visits could become a possible indicator of Medicaid service elimination outcome. This has limited the actionability of the study results for the given management question. Lastly, the sixth step is determining information adequacy (Rundall, 2007). There is sufficient information if needs for accurate, applicable and actionable information are met and clear options for which Medicaid services should be discontinued are clearly delineated ready for management consideration.
For me, the most crucial step in the IDT for decision making in the given management scenario is assessing information accuracy. This is directly tied to data quality which has an impact on both applicability and actionability. In other words, the higher the quality of data, the higher the probability that it would be applicable and actionable, thus making the last two steps easier to perform. For example, high-quality primary research, such as case studies of Medicaid services reduction done in other states, would carefully document such experiences and would include implications, conclusions and recommendations all of which facilitate the practical application of findings in planning and implementation.
Overall, using the toolbox is a catalyst in changing organizational vision, structure, processes, culture and capability (Rundall, 2007). Continuously applying the IDT develops the awareness among members that conventional foundations for decision-making may not be as sound as previously thought. It develops the attitude of challenging long-held ideas and practices and the habit of taking a second look to determine the scientific backing of actions taken (Pfeffer & Sutton, 2006). Subjecting each practice to an evidence test creates a culture of questioning which brings about openness to change in order for questionable practices to be rectified.
One area of change is the organizational structure and processes. Since a questioning organization requires knowledge and information for use in evaluating current practices and to build the evidence base for new ones, members must have the necessary skills in locating, retrieving and evaluating information and the end product must be communicated in order to set the standard, encourage enhancements and prevent duplication of efforts. This gives rise to the knowledge transfer process, the responsibility of which may require an added position in the structure (Rundall, 2007). The process would now become central in the day-to-day operations of the organization.
Using IDT enhances organizational accountability. The toolbox engenders the consciousness that decisions should not be based on whim, gut feeling, tradition or opinion all of which provide no logical proof of what the outcomes would be. By using the newest and the best research evidence available as basis in decision making, the positive results of decisions are ensured. Consequently, there is greater control of the outcomes and a greater exercise of responsibility over them. In effect, IDT is one strategy that can be used to achieve an organization’s mission for continued learning, growth and excellence.
In conclusion, the spill-over of evidence-based practice from the clinical setting to organizational management is embodied in the IDT. It is a highly relevant and easy to use tool for use when faced with managerial issues requiring decision making. Its application requires much thinking and extra efforts at research during decision making which prepares today’s health care managers in coping with current health reforms emphasizing quality and accountability. The use of the IDT in the workplace must be welcomed as a springboard for organizational growth which enhances competitiveness in the health care environment now and in the future.
Abramsky, S. (2011). The Medicaid stress test. The Nation, 2 January 2012, 27-30.
Lowe, R.A., McConnell, K.J., Vogt, M.E., & Smith, J.A. (2008). Impact on Medicaid cutbacks on emergency department use: The Oregon experience. Health Policy and Clinical Practice, 52(6), 626-634.
Pfeffer, J., & Sutton, R.I. (2006). Demanding proof. Industrial Engineer, June 2006, 43-47.
Rundall, T.G., Martelli, P.F., Arroyo, L., McCurdy, R., Graetz, I., Neuworth, E.B., Hsu, J. (2007). The informed decisions toolbox (IDT): Tools for knowledge transfer and performance improvement. Journal of Healthcare Management, 52(5), 325-342.