Insights for improved decision-making

Consulting helps states improve outcomes, policies and operations

State Medicaid agencies face a dual challenge: First, they must respond to immediate operational and policy pressures, including data modernization, rising costs and new federal work and eligibility requirements under the One Big Beautiful Bill Act. Second, they must simultaneously advance long-term efforts to design, implement and improve Medicaid programs.  

Balancing these competing demands requires agencies to make complex decisions, coordinate across stakeholders and translate growing volumes of information into actionable strategies.  

In this article, Tim Prinz, Director, Strategy and Growth for Government Programs at Optum, and Suman Challagulla, Managing Director, OptumServe Consulting, a subsidiary of Optum consulting arm, discuss how a practical consulting approach can help states move from insight to measurable action. 

Start with state priorities and policy objectives

State health leaders are being asked to improve outcomes, control costs, modernize programs and increase accountability. They're also operating with limited staff, funding and time. A strong consulting approach starts with:

• Clarifying the state’s most pressing pain points
• Defining what success looks like
• Prioritizing work in a way that connects near-term action to longer-term program goals  

States often treat value-based payment, accountable care, behavioral health access, maternal health outcomes and financial oversight as separate initiatives. But these priorities don’t have to be pursued in isolation. States can identify strategies that advance multiple priorities simultaneously. Getting clarity upfront helps focus resources where they can have the greatest impact. 

Move from data to action

A disciplined process helps agencies move from a broad challenge to a practical path forward:

1. Gather data securely and privately from the state
2. Prioritize data governance issues
3. Clean and manage the data
4. Apply data analytics tools
5. Identify challenges and root causes
6. Develop recommendations
7. Create implementation roadmap

“We clean and validate the data before turning to the analytics,” says Prinz. “Through the analytics, we come to understand the key challenges, identify root causes, and understand the problem at the deepest level before establishing concrete recommendations and a roadmap for success.”

Look beyond data to understand the full story

Data on its own rarely tells the entire story. Analytics can reveal outcomes that vary across regions, providers, health plans and patient populations. Stakeholder engagement and current-state assessment help explain why those patterns exist and what it will take to address them.   

For example, providers may describe challenges connecting patients to care, while community organizations may point to housing, transportation or food insecurity, factors that rarely surface in claims data alone. 

• Current-state analysis and core Medicaid analytics 
  Problem definition, root cause analysis and full understanding of the problem 
• Data-driven insights
  End-to-end analytics and extensive data resources drive key insights 
• Stakeholder engagement
  Interviews and focus groups to inform program direction 
• Future-state design
  Solutions designed and implemented to address a state's unique needs 
• Implementation activity support 
  Successful program implementation to address the issues identified 
• Post-implementation planning 
  Ongoing data reporting and analytics over the long term 
• Grounded in Medicaid subject-matter expertise 
  Specialized knowledge of Medicaid regulations and practices guides solutions, implementation strategies and insights 

“Current state analysis helps us understand policies, incentives, workflows and operational processes,” says Challagulla. “When we combine that with stakeholder engagement, we have multiple perspectives on how those processes are experienced by providers, community organizations, agency staff and beneficiaries. By bringing those perspectives together, patterns emerge that normally aren’t visible.” 

That same approach supports the move from strategy to execution. Strategic recommendations should include an implementation roadmap, alignment across policy, payment, operations and outcome evaluation, and a clear plan for change management so stakeholders can coalesce around a common goal.

Measure, monitor and adapt

For Medicaid agencies, measurable outcomes should encompass:

• Access
• Quality
• Cost
• Care experience
• Outcomes
• Program integrity 

A strong measurement framework connects policy goals to operational and clinical perspectives so agencies can understand what changed, for whom it changed, why it changed and what should happen next.

The Optum data tools provide states with a clear view of program performance, helping leaders understand whether investments and interventions are delivering the intended results. 

Says Challagulla, “We create the structure, the analytics, the governance and the feedback loop to monitor performance and adjust as a program evolves. We establish baseline measures, define leading and lagging indicators, create rapid-cycle reporting to help the program evolve and continuously communicate with stakeholders.”

At Optum, our federal and Medicaid policy experts, clinicians, actuaries, researchers, evaluation specialists, value-based payment model designers, data scientists and public health experts bring:

• Depth of experience
• Holistic understanding of state health programs
• Practical paths forward

Optum Consulting is tailored to the client’s needs, with no two approaches being exactly the same.

“We listen to the state and work to understand their unique challenges,” Prinz says. “Then, we design a consulting solution that meets those needs head-on.” 

Turn insights into action

Every state’s needs and goals are different, and every agency is at a different place on the continuum. Optum can meet states where they are, help clarify priorities and connect consulting, analytics and implementation support to improve outcomes, policies and operations. The emphasis throughout is partnership – supporting state-led priorities, not replacing them.  

Contact an Optum representative at optum.com/stategovcontact.