Lindsey Leininger: Joining the State Medicaid Agency to Investigate the Effect of Reforms

Lindsey Leininger, whose background is in health services and health policy research, is a senior researcher at Mathematica Policy Research. Her knowledge exchange project at UW-Madison took her to the state Medicaid office, where she spent 20% of her time as a scholar.

Did you know about the knowledge exchange program before you started the Health & Society Scholars program?

It didn’t feel like a requirement or an add-on, it felt integral to what I wanted out of the program.

Yes, it was a big part of why I ended up in HSS and why I ended up at Wisconsin, specifically. When I was interviewing with Dave Kindig [one of the site directors], I told him that I was likely interested in a nonacademic path and that I really wanted to split my time as a scholar between research and practice. I think his eyes perked up, he was really excited about it. He was like, “We can definitely make that happen here.” So I went in seeking that. It didn’t feel like a requirement or an add-on, it felt integral to what I wanted out of the program.

So you viewed knowledge exchange as beneficial to your future career?

Yes. I viewed it as critical for my next step, because I was coming from a traditional academic program. Even though it was at a policy school, which you think ostensibly would promote nonacademic careers, that was not the case. I was trained by very traditional economists, and they really wanted people to do traditional academic careers, so I didn’t really know how I would transition.

How did your project come together?

I showed up at Wisconsin and the universes aligned. Dave helped get me a position at the Medicaid office. He knew the Medicaid director at the time and made that piece happen. But then there was also a project funded by the RWJ Foundation that had just kicked off. The scientific lead was an economist at UW-Madison who I had known a little bit from grad school, and it was an evaluation of a bunch of reforms to the Wisconsin Medicaid program that had happened. My research world and my practice world completely aligned. When I think about my postdoc, I can’t even really separate them because they just bled into each other the entire time. We had administrative data from the program, so we were doing a program evaluation, and we were also meeting with our state counterparts on the evaluation, who we were really close with for those 2 years. Every Tuesday I was working with the chief medical officer of the Medicaid program. All of this really blended together, the lines were very blurred.

Really the integral person was Donna Friedsam (Health Policy Programs Director at UW-Madison), whom Dave knows quite well. I think she’s really the key to the magic in Wisconsin. She knew there was a new RWJF person interested in policy, so she reached out and was like “We just got this grant, are you interested?” And Tom DeLeire (Professor of Public Policy, Georgetown University) was like “We got this grant, are you interested?” And I happened to be working on Medicaid in my dissertation—It was on kids and families on Medicaid, and this was a kids and families on Medicaid project. Donna’s been the one person from that program who has been the most instrumental for my career. Seven years later, I’m still working on projects that have largely been brokered by her.

How did the knowledge exchange work?

They talk about knowledge exchange or knowledge transfer, and I really feel like the knowledge transfer was from them to me. My supervisor at the state, Jonathan Jaffery [currently Chief Population Health Officer at UW-Madison Health], was awesome. He let me tag along to meetings and just observe the natural order of the Medicaid agency. He was new to his role, so he had a lot to learn too. So I think it was helpful. There was a lot of stuff he wanted to know about. I’d be like, “What are you interested in?” He would tell me, and I’d write him a memo.

He was a nephrologist by training, so kids and families on Medicaid were not part of his background. It was totally new to him. He was interested in childhood obesity, knew nothing about it but was interested in it, so I wrote him a 5-pager on that. And once I got a little more embedded, and I got to know some of the people at the agency, there’d be some other more informal requests. I remember one of the staffers wanted to know about quality measurement, a specific flavor of quality measure, so I wrote a memo for her. It was ad hoc.

What did you want to get out of the knowledge exchange?

I think what I’ve really learned and what started taking shape in the program is that my guiding professional interest is using data to improve healthcare delivery.

Exposure, but also experience. At that point I was coming out of a PhD program, 30 years old, and my only work experience was academic. I just didn’t know how I was going to transition. I didn’t know what nonacademic options were out there. I didn’t know how to get nonacademic experience. This was a way to explore without committing. Because if it turned out I hated it, academia could still be an option—I still had some time to write and publish. I think what I’ve really learned and what started taking shape in the program is that my guiding professional interest is using data to improve healthcare delivery.

What was the hardest part of your experience?

Navigating the uncertainty was hard. I needed to make myself useful somehow because it was so amorphous. It wasn’t like I showed up at the Medicaid agency and there was a project and people really needed help with it. I just kind of showed up, and I had a cubicle with what seemed like the world’s first computer. It was so old, I ended up just bringing my laptop in. I had to find a way to make myself useful, which was the biggest challenge.

What was the best part?

The RWJF HSS program is the most formative thing that has happened in my career. It launched my path.

Everything. I can’t pick a best thing. I think the combination of going to the Medicaid office but also working on this evaluation—the RWJF HSS program is the most formative thing that has happened in my career. It launched my path. As a grad school student, I was working with publicly available survey data. This was my first exposure to administrative data, such as claims and eligibility data systems, sort of the bread-and-butter health analytics inputs, which are almost exclusively what I use now. So I got exposure to the kinds of data I’d be using, I got exposure to the kinds of topics I’d be working on. I honest to goodness believe this could not have happened at any site but Wisconsin.

How did you measure the results of the exchange?

Well, I can measure my results in dollars. When I was an academic, I was in a hybrid soft and hard money position. I counted it at one point: About $700,000 worth of grants came directly from my work with Wisconsin. Not all that money went to me, but in terms of what our team brought in. Actually it was more than that, but I counted just the stuff that I was working on. As part of this project, I got my first investigator-initiated grant and first principal investigator role on a large evaluation contract.

My final Wisconsin project ends this year. I am a little sad because this is the end of a very special chapter for me. It’s good and it’s right and it’s time to move on and do federal work and work with other states, but I’ve been working on the Wisconsin stuff for the past 7 years, so it’s hard.

Has knowledge exchange become an important part of your work?

Just before coming here, I was in DC working with states, providing technical assistance, helping them get their data systems up and running so that they can report quality measures for women and kids in Medicaid. So this is a total continuation. Here I am, all these years later, doing really similar things.

For what kind of scholars do you think knowledge exchange would be especially valuable?

I think people post-tenure could probably benefit from this a lot because they have more time and they have less pressure. They might be looking for new challenges. There can be a lot of research burnout in getting tenure. People are still productive, they’re probably a little sick of what they’ve been doing, and they want new challenges, but it’s not so risky for them, there aren’t huge opportunity costs to their time.

There might be some people who just want to go into their office and close the door and do their work, and we should honor that. I don’t think knowledge exchange should be forced, because I don’t think it’s going to be successful.