TY - JOUR
AU - Searing, Elizabeth A, M
AB - Abstract The nature of the interactions between the organizational entities involved in contracting receives less attention than the efficiency of the procurement and distribution of those services. This is particularly true in periods of policy turbulence, where tensions are high and environments unstable. This study builds on earlier theoretical contributions by cataloging almost 100 different strategies in interviews with state agencies and related policy experts, then distilling important traits and modifying earlier analytical constructs to reflect the empirical findings. The result is a new understanding of the range of relationships and extent of collaboration in contracting interactions at different points in the policy process. This study contributes to the literature not only through the elicitation and nature of these contracting strategies but also by contributing to the theoretical underpinnings of both collaboration in contracting and how such relationships provide a means of navigating periods of policy turbulence. Introduction The proliferation of collaborative endeavors that involve state and non-state actors has engaged the attention of public administration and public management researchers for many years. At the same time as these fields were virtually exploding with studies related to collaborative phenomena (e.g., the special issues of Journal of Public Administration Research and Theory edited by Heinrich, Lynn, and Milward in 2010 and of Public Administration Review edited by O’Leary, Bingham, and Gerard in 2006), Van Slyke (2009) argued that the intersection between collaboration and contracting was an under-examined phenomenon. Although a number of important studies of relationships involved in contracting were published in the same period,1 the nature and extent of collaboration internal to contracting interactions and variations in collaborative contracting relationships across the policy process remain undertheorized, particularly in situations of unusually severe policy turbulence. This study builds on earlier theoretical contributions by cataloging almost 100 different strategies in interviews with state agency contract managers and related policy experts, then distilling important traits and modifying earlier analytical constructs to reflect the empirical findings. The result is a new understanding of the range of relationships and extent of collaboration in contracting interactions at different points in the policy process. Three research questions structured our inquiry. First, since we sought an empirical grounding for our theorizing, we wanted to know what strategies public agencies relied on when acting in the context of a persistently turbulent policy subfield. Since descriptions of policy turbulence in the literature closely matched those in the Medicaid Managed Care children’s health care subfield, we conducted semi-structured interviews with individuals working for or with state agencies regarding the transition in children’s health to Medicaid Managed Care in New York State. The second and third questions drilled into the sector location of the actors engaged by the strategies and the theory underscoring them: to what extent do the responses include multi-sector strategies, and do the multi-sector strategies reflect transactional elements, relational elements, or both? All three questions reflect the field’s continued interest in cross-sector interdependence in the context of contracting and the extent to which the deep and multi-layered resource interdependence between government, nonprofit organizations, and for-profit organizations, is manifest in multi-sector public management approaches. This study also contributes to empirically informed research on the nature and dynamics of contracting. Public management scholars (such as Amirkhanyan, Kim, and Lambright 2012; Bertelli and Smith 2010; Brown, Potoski, and Van Slyke 2010; Johnston and Romzek 2008; Van Slyke 2007, 2009) emphasize endogenous elements in contracting such as the completeness or incompleteness, stability or instability, and degree of formality of the contract document and the presence or absence of trust and credibility among contracting actors to explain relationship dynamics. By contrast, we examine the association between exogenous characteristics of the policy environment itself and the tilt of contracting relationships toward transactional or relational interactions. Similar to the recent article by Nohrstedt et al. (2018) on collaboration and crisis management, we posit that these external elements, such as degree and extent of turbulence and phase of the policy process, will impact the choice of strategy. This study contributes to the literature not only through careful empirical work on the elicitation and nature of these contracting management strategies but also by contributing to the theoretical foundations of both collaboration in contracting and how such relationships provide a means of navigating periods of extended policy turbulence. We document co-occurring interactions between state and non-state contracting actors that are not fundamentally collaborative in nature, as well as actions undertaken wholly within the public sector. We found that not only are contracting strategies sometimes intentionally not collaborative but that organizations wisely use a portfolio of these approaches based on certain factors in order to manage the contracts in a particular policy scenario. Further, strategies vary in a systematic way across stages of the policy process. The following sections begin with a review of the theoretical literature on contracting relationships published in the last 20 years. We then describe our methodology. Next, we present our findings on strategies used by state agencies to navigate and manage contracting relationships during protracted policy turbulence. We use analytical tools such as policy governance continua and an environmental turbulence framework (Ansell and Trondal 2018) as lenses to examine the findings from the perspective of the influence of environmental conditions on organizational and inter-organizational actions. Policy governance continua are graphic visualizations that capture dynamic variations in interactions among policy actors. In this case, the actors are governmental and nongovernmental organizations involved in contracting. This analytical tool and the Ansell and Trondal (2018) environmental turbulence framework are described in detail below. Finally, we return in conclusion to the particular contributions that this analysis offers and suggest additional research possibilities. Theorizing Contracting Relationships Following the initial stage in the 1980s and 1990s of scholarly inquiry into the expanded contract-based structure of government-nonprofit relations, a number of new frameworks, models, and constructs began to appear in the research literature. The new formulations offered alternative ways of conceptualizing the dynamics of contracting relationships between the sectors. These often-overlapping theoretical approaches included: a tools framework (Salamon 2002); a multidimensional contracting model (Cooper 2003); relational contracting as a cross-sector governance construct; and policy continuum models (Saidel 2011, 2017; Van Slyke 2007). Relational contracting received especially extensive analytical and empirical attention (see, for instance, Amirkhanyan, Kim, and Lambright 2012; Bertelli and Smith 2010; Fernandez 2007; Saidel 2013; Sclar 2000; Van Slyke 2009). The “Tools” Framework In the 2002 volume, The Tools of Government, A Guide to the New Governance, Salamon introduced the “new governance” paradigm that captures what he described as “a fundamental transformation not just in the scope and scale of government action, but in its basic forms” (1). He identified different mechanisms, such as loans and loan guarantees, vouchers, and contracting, that government now employs to deal with public problems. A major contribution of the tools framework is Salamon’s insistence that the expanded number of tools utilized by government to accomplish public purposes has “vastly complicated the task of public management” (Salamon 2002, 6). Not only is public management more complex, according to Salamon, it has also been transformed from the traditional, bureaucratic, top–down model of governing to the more collaborative dynamic inherent in a governance system in which government relies on third parties to deliver public programs. The skills of negotiation, persuasion, mobilizing and marketing, incentivizing desired, and penalizing noncompliant behaviors are the management competencies highlighted in the DeHoog and Salamon “Purchase-of-Service Contracting” chapter (2002). Multidimensional Contracting Model In Governing by Contract, Challenges and Opportunities for Public Managers, Cooper (2003) argued for a model based on the simultaneous existence of both vertical, authority-based and horizontal, negotiation-based inter-organizational dynamics in cross-sector contracting processes. Thus, both for public contract management in particular and for contemporary governance more generally, it is important to understand that two quite different models of behavior are in operation at the same time. The challenge for the public manager is that he or she operates at the intersection of the two models, which is precisely the cause of many of the challenges that the manager faces (48). The substantial insights here are the concurrent operation of two very different management imperatives and the location of the public contract manager at the nexus. “This tension between the vertical and horizontal models provides the essential tension in public contract administration” (49).2 The model’s emphasis on the simultaneous operation of vertical and horizontal relationship dynamics in the governance of contemporary contracting widens the lens through which to understand the public management challenges involved in contracting and, thereby, adds depth to Salamon’s (2002) contention that public governance has been transformed from one dynamic to the other. Another of Cooper’s (2003) key contributions is a fundamental theme that underpins the entire analysis: One of the greatest barriers to improving the administration of public programs in an era of extensive contracted operations is the failure to understand the nature of the relationships that emerge in that process (55).3 Cooper’s focus on managing relationships in the contracting process parallels the emergence in the theoretical public governance literature of relational contracting as a cross-sector governance construct. The Relational Contracting Construct As early as 1978, legal scholar Ian Macneil described the evolution from classical through neoclassical to relational contract law, thereby elaborating a broad legal framework within which to understand what is happening in public governance today. Relational contracting, according to Macneil, is a way to balance the “need for reliability of planning and the need for flexibility in economic relations” (Mcneil 1978, 888). Among public governance scholars, relational contracting is defined as interactions between contracting actors that are collaborative, flexible, non-adversarial, mutually problem solving, and characterized by trust and frequent communications, which minimize transaction costs (See Fernandez 2007 for a literature review of definitional elements). The construct captures a set of relationship dynamics that contrast dramatically with the principal-agent interactions characteristic of a vertical, top–down approach to contracting that relies heavily on regulation, monitoring, and formal anti-shirking and anti-opportunism incentives. Among many scholars of public contracting (e.g., Amirkhanyan, Kim and Lambright 2011; Beinecke and DeFillippi 1999; Bertelli and Smith 2010; DeHoog 1990; Feeney and Smith 2008; Fernandez 2007; Johnston and Romzek 2008; Sclar 2000; Van Slyke 2009) a consensus has emerged around the idea that relational contracting is the form of multi-sector interaction that fits best with the social services policy arena. Why is this the case? The social service domain is often characterized by limited competition, outcomes that are difficult to measure, persistent fiscal constraints, and turbulent environmental uncertainty. The flexibility and negotiation, envisioned by Mcneil (1978) as characteristic of relational contracting, are well suited to these environmental and programmatic conditions. Using an elaborate data set built from surveys conducted by the International City Managers Association (ICMA), Fernandez (2007) conducted a comprehensive quantitative study of factors potentially related to contracting success between local governments in the United States and for-profit and nonprofit contractors. He found that success in social service contracting is associated with many of the definitional elements of relational contracting, such as programmatic flexibility and back-and-forth exchanges that occur often between public managers and contractors. In short, these findings suggest that experts on contracting have overestimated the impact of contract management practices aimed at controlling and programming the contractual relationship, and, conversely, that greater attention must be given to factors that build trust between the parties and facilitate problem solving and mutual adjustment to meet unforeseen circumstances (1136). In this analysis, Fernandez contrasts transactional practices characteristic of principal-agent contracting relationships with key dimensions of relational contracting. Policy Continuum Models As important work on relational contracting appeared in various public affairs journals, some scholars were wrestling with how to theorize the dynamic character of government-nonprofit relationships and adaptive changes over time in contract management strategies. In a widely cited empirical study, Van Slyke (2007) documented “evolved principal-agent relationships” (169) in which principal-agent practices such as strict compliance expectations and regular, formalized monitoring were relaxed by public managers. “The contract relationships often began as principal-agent-type relationships and evolved into steward-type relations in which trust, information exchange, involvement, and discretion were used” (170). Another attempt to meet this theoretical challenge was Saidel’s studies (Saidel 2011, 2017) that posited a circular policy governance continuum anchored by transactional principal-agent interactions at one point and relational contracting interactions at another point.4 Elements of both kinds of relationships are often apparent in the same set of inter-organizational linkages that are sometimes closer to the transactional point of the continuum and, at other times, closer to the relational point (see also Amirkhanyan, Kim, and Lambright 2010, 193). The continuum is an integrative framework that captures the range of dynamic cross-sector institutional relationships in the contracting regime.5 A continuum, with contracting relationships along its expanse always potentially in motion, facilitates analysis of different management challenges for public contract administrators. Both Saidel (2011, 2017) and Van Slyke (2007) emphasized the importance of political and economic environmental influences in determining the character of cross-sector contracting relationships at particular historical periods.6 Collaboration and Contracting Research examination of collaborative relationships internal to the contracting process has appeared in several important studies within the last 10 years.7 In 2009, Van Slyke argued: Collaboration and contracting are not antithetical to one another. Indeed, successful contract relationships often involve some degree of collaboration between the buyer (government) and seller (nonprofits). However, what is less well known is what these collaborative practices are and under what conditions each party enacts them (140). In a study of social services contracting in New York State, he found that trust-based relationships, developed over time through ongoing communication and interaction, resulted in more joint participation in contract goal development, approaches to implementation, and methods of determining effective performance and satisfactory outcomes. These collaborative relationships and shared processes evolving in the context of a formal, legal contract are defining elements of relational contracting. Amirkhanyan, Kim, and Lambright (2010) situate relational contracting at the center of their Ohio study of the association between relationship strength and performance by contractors in the child care subfield. Of particular interest to the analysis reported here are the two ways in which the authors measure relationship strength. Variables included in current relationship strength are: shared procedures; goal agreement; communication quality; and cooperation in contract implementation. Collaborative contract development is the other measure of relationship strength. Several years later, in an article with the term “collaborative contracting” in the title, the same research team (Amirkhanyan, Kim, and Lambright 2012) focused on relational contracting from a different angle. Utilizing the Ohio child care data, they examined the association between formal contract specification and relational contracting practices described as “collaborative relationship strength” (Amirkhanyan, Kim, and Lambright 2012, 345). The study’s principal finding is that carefully specified contracts and, the authors speculate, interactions between the parties in the contract development phase, are positively related to collaborative relationships between contracting actors. Utilizing a multiple case study design, Romzek et al. (2014) investigated informal accountability relationships and behaviors in three multi-sector child welfare service networks. They find that a facilitative behavior described as “relationship building” is an important contributor to informal accountability processes. Along with other informal facilitative behaviors such as ongoing communication and information sharing, relationship building parallels the characteristics of relational or collaborative contracting. As is common with concepts that transcend disciplinary boundaries, some semantic ambiguity characterizes the terms “collaboration” and “collaborative governance” as applied to contracting. Building on the significant research foundation cited in this section, we suggest that relational contracting is one type of the much broader umbrella construct “collaborative governance.” In this article, we seek to identify and deepen understanding of the range of public agency strategies utilized in contracting processes unfolding in an environment of severe and prolonged environmental turbulence. We anticipate that both transactional and relational or collaborative elements will be apparent in the strategies. Of particular interest will be the distribution of the strategies across various phases of the policy process. Methodology To address the research questions, the authors began with gathering archival and documentary evidence regarding the MMC policy environment. Using this information, we identified government agencies at both the state and county level that would be most active in the MMC transition. We identified people within those agencies most embedded in the context, utilizing the snowballing technique to expand our respondent pool. Then we conducted 21 semi-structured interviews with individuals who were either state agency employees (11), county employees (4), or other local experts in the field of Medicaid managed care (6). The list of the employment location or function of the respondents that participated is included in table 1. Table 1. Interview Participants Code . Employer or Function . G1 NYS Department of Health G2 NYS Office of Child and Family Services G3 NYS Office of Mental Health G4 NYS State Education Department G5 County 1 Department of Social Services G6 County 1 Department of Social Services G7 NYS Office of Mental Health G8 NYS Office for People with Developmental Disabilities G9 NYS Department of Health G10 NYS Office of Alcoholism and Substance Abuse Services G11 NYS Office of Mental Health G12 County 2 Department of Social Services G13 NYS Office of Alcoholism and Substance Abuse Services G14 NYS Department of Health G15 County 3 Department of Social Services P1 Health Plan P2 Health Plan P3 Provider R1 Provider/Expert R2 Expert R3 Expert Code . Employer or Function . G1 NYS Department of Health G2 NYS Office of Child and Family Services G3 NYS Office of Mental Health G4 NYS State Education Department G5 County 1 Department of Social Services G6 County 1 Department of Social Services G7 NYS Office of Mental Health G8 NYS Office for People with Developmental Disabilities G9 NYS Department of Health G10 NYS Office of Alcoholism and Substance Abuse Services G11 NYS Office of Mental Health G12 County 2 Department of Social Services G13 NYS Office of Alcoholism and Substance Abuse Services G14 NYS Department of Health G15 County 3 Department of Social Services P1 Health Plan P2 Health Plan P3 Provider R1 Provider/Expert R2 Expert R3 Expert Open in new tab Table 1. Interview Participants Code . Employer or Function . G1 NYS Department of Health G2 NYS Office of Child and Family Services G3 NYS Office of Mental Health G4 NYS State Education Department G5 County 1 Department of Social Services G6 County 1 Department of Social Services G7 NYS Office of Mental Health G8 NYS Office for People with Developmental Disabilities G9 NYS Department of Health G10 NYS Office of Alcoholism and Substance Abuse Services G11 NYS Office of Mental Health G12 County 2 Department of Social Services G13 NYS Office of Alcoholism and Substance Abuse Services G14 NYS Department of Health G15 County 3 Department of Social Services P1 Health Plan P2 Health Plan P3 Provider R1 Provider/Expert R2 Expert R3 Expert Code . Employer or Function . G1 NYS Department of Health G2 NYS Office of Child and Family Services G3 NYS Office of Mental Health G4 NYS State Education Department G5 County 1 Department of Social Services G6 County 1 Department of Social Services G7 NYS Office of Mental Health G8 NYS Office for People with Developmental Disabilities G9 NYS Department of Health G10 NYS Office of Alcoholism and Substance Abuse Services G11 NYS Office of Mental Health G12 County 2 Department of Social Services G13 NYS Office of Alcoholism and Substance Abuse Services G14 NYS Department of Health G15 County 3 Department of Social Services P1 Health Plan P2 Health Plan P3 Provider R1 Provider/Expert R2 Expert R3 Expert Open in new tab The latter category contained local consultants, nonprofits, health plans, and attorneys that helped corroborate and triangulate the information given by the government employees. Each interview contained both biographical and open-ended questions regarding the management strategies used in the MMC policy environment. We conducted a qualitative conventional content analysis to establish different strategies (Hsieh and Shannon 2005; Wiley and Berry 2018). Though one of the questions was specifically designed to elicit thoughts on cross-sector collaboration, this is not sufficient to consider the content analysis a directed one (Potter and Levine-Donnerstein 1999). The original analysis yielded 99 different strategies and approaches, and we conducted iterative coding to reduce and clarify these strategies into 12 distinct strategies in accordance with the data reduction approaches of Miles and Huberman (1994). These final emergent strategies were then reevaluated against our expectations based on theory. To minimize research bias, all interviews were recorded, transcribed, and analyzed using the Nvivo software system.8 Approximately half of the interviews were conducted with both team members present to minimize interviewer-related impacts on the data collection, and both members coded all transcripts. Any discrepancies in coding were discussed until the issue was resolved. The interview protocols for both state agency employees and non-state experts are available in the Appendix 1 and 2. Following the cataloging of the approaches and their distillation into strategies, we use two analytical tools from the literature to organize the characteristics of the contracting relationships. First, we determine the scope and role of the parties involved in the strategy to evaluate the degree of collaboration used. This scale includes Multi-sector, Within-sector, and Within-organization strategies; technically, autocratic single-person strategies could also be included, but none were discovered. Second, we examine their location on a governance continuum anchored by transactional interactions at one endpoint and relational interactions at the other endpoint (Saidel 2011, 2017; Van Slyke 2009). As mentioned previously, the continuum is a conceptual device designed to capture the dynamic, multi-directional nature of cross-sector, inter-organizational relationships within a contracting system. By incorporating both transactional and relational elements along its expanse, the continuum metaphor surfaces the possibility that both can occur simultaneously within contracting relationships. To determine a strategy’s location on the continuum, we evaluated whether the parties involved all had similar degrees of participation, agency, and autonomy. If there was an imbalance indicative of transactional approaches found in the literature, the placement on the continuum reflected this. Since the 12 strategies reflect combinations of grouped similar strategies, the use of the continuum also allowed for the display of nuance that would otherwise be lost in a coarser system of categorization. Case Description: The Policy Turbulence of Medicaid Managed Care for Children’s Services The Importance of Policy Turbulence In early 2015, a local nonprofit “reflective practitioner” (Schön 1983) in the field of human services made a comment to one of this article’s authors: “[y]ou know, the circumstances of contracting are changing drastically.” Coincidentally, as the author team began the data analysis phase of this multiyear study, the inaugural issue of Perspectives on Public Management and Governance was published. It included a valuable theory-building article titled “Governing Turbulence: An Organizational-Institutional Agenda.” Authors Ansell and Trondal offered a comprehensive understanding of the “turbulence” construct in order, in their words, “to direct analytical attention towards how governing organizations handle unstable, unsettled and fluid public domains” (Ansell and Trondal 2018, 44). The policy domain description in the article mirrored closely the health care environment we were examining—a state-based policy environment in which the implementation of managed care into the nontraditional children’s health and human services segments of the Medicaid system was underway. Although managed care had been a feature of the adult Medicaid system for many years, its introduction into children’s behavioral health care and social services such as foster care was a significant departure from long-established practices.9 The Ansell and Trondal (2018) article provides important criteria by which to select a policy environment to evaluate contracting strategies. This is especially the case with respect to their clearly delineated linkages between environmental turbulence and inter-organizational interdependence (45) and between environmental turbulence and collaborative governance (51). The Medicaid Managed Care context offered the opportunity to study a policy environment that was subject to substantial turbulence and contained several different types of contracts.10 Though not yielding econometric data, studying the contents of a policy scenario offers an advantage over many of the larger-n contracting studies that focus on a specific type of contract. Unlike prior studies, we are able to take a more holistic view of the strategy portfolio an organization might employ in a given policy context, rather than focusing on the traits of a single type of interaction employed in many different policy contexts. Therefore, the choice of policy environment was critical to the richness of our insights and depth of the possible contribution. Medicaid Managed Care offered the opportunity for involvement by multiple sectors in a human services context that has already proven to be fertile ground for collaborative contracting. Further, the newer literature on policy turbulence leads us to expect that such a turbulent environment is an ideal environment for finding collaborative contracting strategies. Characteristics of the Medicaid Managed Care Transition Context On January 5, 2011, New York State Governor Andrew M. Cuomo signed Executive Order No. 5, Establishing the Medicaid Redesign Team (9 CRR-NY 8.5 2011). The first, second, and fifth of the seven introductory “whereas” clauses convey the parameters of the national and New York State policy environments in which the order was issued: Whereas, New York State spends more than twice the national average on Medicaid on a per capita basis and spending per enrollee is the second highest in the nation; Whereas, New York ranks 21st out of all states for overall health system quality and 50th for avoidable hospital use and costs; Whereas, New York State faces serious financial challenges in achieving a balanced budget in the 2011–12 State Fiscal Year. Underpinning the Executive Order was the reality of Medicaid spending in 2011 of nearly $53 billion on behalf of 5 million people, a spending level that had recently been increasing significantly. In addition, quality issues such as avoidable hospital utilization and wide health disparities among New York’s highly diverse demographic groups continued to stymie previously implemented corrective measures. Governor Cuomo envisioned a radical, perhaps even disruptive, new approach, moving away from the long-standing fee-for-service system11 to a new managed care arrangement that would introduce new structures and players into a health care arena characterized by often decades-old institutional and interpersonal relationships. Direct contract- related interactions between state agency and nonprofit managers with lengthy shared experiences had created a relatively stable, though still sometimes contentious, environment. Now, however, as Emery and Trist observed in a ground-breaking article cited by Ansell and Trondal, a new set of actors was to be introduced into the policy subfield of children’s nontraditional health and social services and the “ground” was going to be “in motion” (Ansell and Trondal 2018, 45), creating profound environmental turbulence.12 The 27-member original Medicaid Redesign Team (MRT) comprised public administrators, legislators, and stakeholders with relevant health care expertise from a wide variety of groups. Though industry groups had been involved in Medicaid reform before, the MRT was a high-profile example of a new “blended hybrid” structure (Ansell and Trondal 2018, 52) that responds to environmental turbulence and blends the institutional logics of government, business, and the nonprofit sector. The Team was charged with unusually broad responsibility to recommend fundamental changes to the Medicaid system for purposes of substantial cost reductions and to submit its first report on or before March 1, 2011 (Executive Order No. 5, 9 CRR-NY 8.5). This was all conducted with significant publicity, which helped elevate the discussion beyond informal working groups, which may have existed in the past. Accordingly, in February, the Team completed a report with 79 recommendations, of which 78 were part of the enacted budget (Community Health Care Association of New York State 2018). Ten MRT work groups were subsequently established to advance the Team’s work and develop guidelines for health care changes to be implemented over several years. Given the extraordinary complexity and inter-governmental nature of health care reform, it is not surprising that the policy, regulatory, and administrative changes involved require many years to come to fruition. For instance, in April 2014, 3 years after the Executive Order was promulgated, Governor Cuomo announced that a final agreement had been reached with the federal government for the Medicaid 1115 waiver that essentially permitted the transformation of New York State’s Medicaid system (New York State Department of Health 2019a). Now, almost 5 years later, the implementation of Medicaid managed care for children’s nontraditional health and human services is still a source of significant turbulence. Three new benefits were added to Children’s MMC in January of 2019: non-physician licensed behavioral health practitioners, community psychiatric support and treatment, and psychosocial rehabilitation services (Molina Healthcare of New York 2019). Pending federal approval, the bulk of the children and youth being served by the Children’s Waiver program were also scheduled to transition to MMC in October of 2019 (New York State Department of Health 2019c). Children and youth in foster care are scheduled to transition to MMC in July of 2020 (New York Department of Health 2020). Notably, none of these dates had been set during the time period when our interviews took place, and federal review was taking place in June 2019 for the October 2019 changes. The scale of the changes combined with the uncertainty, pace, and complexity cause the turbulence. What are the defining characteristics of the current Medicaid managed care (MCC) policy context in New York State? Based on a 2011 New York State Department of Health document, A Plan to Transform the Empire State’s Medicaid Program, we initiated the investigation with the understanding, later substantiated by the changes in players involved and payment protocols recommended and adopted, that the policy changes envisioned were non-incremental in scale and scope. The document describes the changes proposed as “sweeping” and concludes the Introduction with the observation that “New York is poised to fundamentally transform its Medicaid program…” (New York State Department of Health 2016). Inasmuch as the text of the document, produced by a remarkably complex, hierarchical bureaucracy, described the Medicaid managed care policy changes as dramatic, perhaps even historic, we were convinced that this policy context was particularly suitable for a study of the range of public management strategies utilized in a multi-sector policy arena. We also knew in 2015, several years after the document was released, that the significant changes envisioned were unfolding over a prolonged period of turbulence and uncertainty. These impressions were substantiated by observations about the scope of change related to Medicaid Managed Care reform in children’s services made by nonprofit executives in a concurrent study published that year: “a new paradigm that never happened before,” “an epochal change,” transformational, completely transformational” (Saidel 2013) According to a report published by the New York State Coalition for Children’s Mental Health Services, The important words about behavioral health [in three relevant documents] constitute an almost unimaginable leap forward in a relative nanosecond on the clock of public policy (Schimmer, 2014, 9). Policy Turbulence and Medicaid Managed Care for Children’s Services A key defining characteristic of the policy environment we were studying is the prolonged nature of environmental turbulence, as documented in the paragraphs above and the uncertainty it provokes (Ansell and Trondal 2018). As one public manager observed: “So, nobody really knows how that’s all going to play out.” Referring to federal-state negotiations around Medicaid managed care reform, another manager commented: “…so I’m getting the impression that nobody anywhere knows what the heck is happening and everybody is just kind of waiting for a shoe to drop certainly at the staff level.” The scope and complexity of change in the MMC environment were also apparent to state agency managers whose observations (table 2) were reported in an earlier study (Saidel 2017). Table 2. Descriptive Language about Scope of Change “It’s a huge, huge shift, lots of implications there.” “It’s different from anything we’ve done before.” “the biggest single challenge and change in the history of our services” “the scope of this is potentially very ground-breaking” “We are in a whole new world.” “a massive change” “So, I’ve been a provider, clinical director, private practitioner in the field of mental health and/or substance abuse for probably pushing on 30 years now. I’ve never seen anything like this. The kind of change that’s being pushed for…” “It’s a huge, huge shift, lots of implications there.” “It’s different from anything we’ve done before.” “the biggest single challenge and change in the history of our services” “the scope of this is potentially very ground-breaking” “We are in a whole new world.” “a massive change” “So, I’ve been a provider, clinical director, private practitioner in the field of mental health and/or substance abuse for probably pushing on 30 years now. I’ve never seen anything like this. The kind of change that’s being pushed for…” Open in new tab Table 2. Descriptive Language about Scope of Change “It’s a huge, huge shift, lots of implications there.” “It’s different from anything we’ve done before.” “the biggest single challenge and change in the history of our services” “the scope of this is potentially very ground-breaking” “We are in a whole new world.” “a massive change” “So, I’ve been a provider, clinical director, private practitioner in the field of mental health and/or substance abuse for probably pushing on 30 years now. I’ve never seen anything like this. The kind of change that’s being pushed for…” “It’s a huge, huge shift, lots of implications there.” “It’s different from anything we’ve done before.” “the biggest single challenge and change in the history of our services” “the scope of this is potentially very ground-breaking” “We are in a whole new world.” “a massive change” “So, I’ve been a provider, clinical director, private practitioner in the field of mental health and/or substance abuse for probably pushing on 30 years now. I’ve never seen anything like this. The kind of change that’s being pushed for…” Open in new tab The magnitude, complexity, and unpredictable periods of accelerated pace in the implementation of Medicaid managed care fit closely with the defining characteristics of Ansell and Trondal’s (2018) proposed level one, first type of turbulence—turbulent environments. Based on a consensus among our public sector respondents about the nature of the Medicaid managed care policy subfield, we expand the Ansell and Trondal (2018) level one turbulent environment category to include duration. A constant churn of change and persistently turbulent environment can have impacts attributable to the length of time the environment is endured; this is consistent with the economic literature on the difference between weathering sudden shocks and weathering persistent economic uncertainty (Giuliano and Spilimbergo 2014; Oreopoulos, Von Wachter, and Heisz 2012; Searing 2013). Another level of turbulence identified by Ansell and Trondal is “turbulence of scale,” “when what happens at one level of authority or scale of activity affects what happens at another level or scale” (Ansell and Trondal 2018, 46). The multi-sector and inter-governmental processes that characterize the contracting regime clearly fall within the turbulence of scale category. In addition to finding turbulence and uncertainty in the Medicaid managed care environment through objective documents and subjective perceptions, we also found significant evidence of what Ansell and Trondal term “shifting parameters” (Ansell and Trondal 2018, 45), that is, circumstances in which the usual elements of institutional operations are undergoing change and the shape of the new elements is unclear. Several respondents emphasized the new structural reality of moving from long-standing dyadic state-nonprofit relationships to new relationships in which the roles of managed care companies to confirm eligibility and then make payment for services delivered will be located structurally between government and nonprofit providers. Although managed care companies were already significant players in some policy subfields such as adult health services, the changes envisioned in the children’s nontraditional health and human services arena were dramatic and not yet clearly delineated. One public agency manager observed: “In a managed care world, where their [nonprofit providers’] contract goes up to the managed care company, you [the public agency] have a much more indirect relationship with the provider.” It was clear from responses of managers in several different agencies that the contours of the new agency role were not yet fully understood. A representative comment is: And so we have this sort of third party role now as being the monitoring, oversight agency but not controlling the purse strings necessarily. It’s kind of causing us to ask what exactly is our role evolving into. As mentioned earlier, Ansell and Trondal’s (2018) link between turbulence and collaborative governance is particularly relevant to this study. Citing earlier research, they make the case that “turbulence creates a demand for cross-sector partnerships” (2008, 251; see also Bryson, Crosby, and Stone 2006, 46). Our findings suggest that, in the case of the extension of Medicaid managed care to children’s nontraditional health and human services, the prolonged turbulence and related pervasive policy uncertainty associated with the major changes it entailed have generally pushed the contracting system of cross-sector relationships away from transactional interactions and toward more relational or collaborative interactions. However, the degree to which this explanation is incomplete actually hints at a larger finding: that contracting strategies are nuanced and diverse by design, and that a portfolio of strategies employing situation-dependent characteristics may not just be the reality, but the ideal. The Nature of Strategies Used to Navigate Policy Turbulence This section presents and discusses our findings regarding the types and characteristics of the strategies used by the agencies in order to navigate the MMC environment, including whether any of these strategies are cross-sectoral. The strategies were generated by the collection of 99 examples of interactions or approaches either directly given or alluded to by interviewees. These examples were then coded and grouped to create 12 overall strategies, each of which was then evaluated along the transactional-relational continuum of Saidel (2017) and Van Slyke (2009). In addition, each strategy was coded according to whether it was cross-sector, inter-organizational, or intra-organizational based on the nature and degree of involvement of relevant parties. Stages of Contracting Process One of the elements which emerged during the axial coding was that the stage of the process mattered in strategy choice. The notion of stages is well-known in public policy development, though there is little consensus on how many there are and what they should be labeled (Howlett, McConnell, and Perl 2015). Most schema contain some kind of initial information-gathering stage(s), followed by stages dedicated to design, implementation, and evaluation (Brewer 1974; Lasswell 1956). Due to both this lack of specific consensus and our particular interest in the contracting, we took a functional approach and allowed the stages to emerge as a part of the axial coding. We distill and label these three stages as capacity-building, policy development, and implementation, and we use these categories as a convenient method of displaying our findings. The strategies are shown in tables 3–5, with the number of individual mentions by interviewees following the strategy in parentheses. Of that number, two examples that are particularly illustrative are listed. Table 3. Capacity-Building Strategies Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<X---------->Relation X C1. Building org capacity and technical assistance (4) ○ State building org capacity for provider through incentives or technical assistance ○ State building capacity for plans, such as “readiness reviews” Transact<X---------->Relation X X C2. Creating new infrastructure and reallocating internal resources (8) ○ State creates new infrastructure for state agencies ○ State agencies are under-resourced, too Transact<----------X>Relation X X C3. Fostering collaboration (15) ○ State fosters collaboration between providers, such as encouraging the mergers of “mom and pop” organizations ○ State fosters collaboration between plans and providers; between state agencies and plans, and system-wide (new Regional Planning Consortiums) Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<X---------->Relation X C1. Building org capacity and technical assistance (4) ○ State building org capacity for provider through incentives or technical assistance ○ State building capacity for plans, such as “readiness reviews” Transact<X---------->Relation X X C2. Creating new infrastructure and reallocating internal resources (8) ○ State creates new infrastructure for state agencies ○ State agencies are under-resourced, too Transact<----------X>Relation X X C3. Fostering collaboration (15) ○ State fosters collaboration between providers, such as encouraging the mergers of “mom and pop” organizations ○ State fosters collaboration between plans and providers; between state agencies and plans, and system-wide (new Regional Planning Consortiums) Note: The number of unique examples offered by individuals is represented in parentheses after the strategy. Open in new tab Table 3. Capacity-Building Strategies Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<X---------->Relation X C1. Building org capacity and technical assistance (4) ○ State building org capacity for provider through incentives or technical assistance ○ State building capacity for plans, such as “readiness reviews” Transact<X---------->Relation X X C2. Creating new infrastructure and reallocating internal resources (8) ○ State creates new infrastructure for state agencies ○ State agencies are under-resourced, too Transact<----------X>Relation X X C3. Fostering collaboration (15) ○ State fosters collaboration between providers, such as encouraging the mergers of “mom and pop” organizations ○ State fosters collaboration between plans and providers; between state agencies and plans, and system-wide (new Regional Planning Consortiums) Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<X---------->Relation X C1. Building org capacity and technical assistance (4) ○ State building org capacity for provider through incentives or technical assistance ○ State building capacity for plans, such as “readiness reviews” Transact<X---------->Relation X X C2. Creating new infrastructure and reallocating internal resources (8) ○ State creates new infrastructure for state agencies ○ State agencies are under-resourced, too Transact<----------X>Relation X X C3. Fostering collaboration (15) ○ State fosters collaboration between providers, such as encouraging the mergers of “mom and pop” organizations ○ State fosters collaboration between plans and providers; between state agencies and plans, and system-wide (new Regional Planning Consortiums) Note: The number of unique examples offered by individuals is represented in parentheses after the strategy. Open in new tab We found three strategies that focus on the development of capacity; please see table 4 for details. All three strategies involved language on preparing for implementation, in addition to the development of skills in one or more of the parties in the MMC context. Common to other policy scenarios, the State was concerned about the ability of other participants in the MMC ecosystem to understand the complex nature of things like risk in value-based payments. What was unique about MMC was that the State leveraged some of this capacity-building at their own cost (such as the support of a center for technical assistance at a local university) or through requirements that were onerous to them (such as hosting “readiness reviews.”). The state agencies were quick to point out that a lack of capacity did not only apply to other sectors: many expressed concerns that their own efforts were under-resourced, even with the creation of new infrastructure within their agencies, such as a new division at the Office of Mental Health. Table 4. Policy Development Strategies Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<-----X----->Relation X X PD1. Formal meetings/calls/working groups, cross-sector (8) ○ Always been meetings, but “new element to these is consensus” ○ Non-contracting structures/ “speed dating” Transact<X---------->Relation X PD2. Use contracting process and clear provisions to achieve mission goals (17) ○ Protect access to care and ensure that “everyone gets paid” ○ Risk sharing and functional amendment process Transact<-----X----->Relation X PD3. Stakeholder engagement in policy (8) ○ High level and frequency of communications ○ Capitalizing or aligning on similar motivesa Transact<--X-------->Relation X PD4. Adaptive learning process (5) ○ Thorough and ongoing reviews to protect providers from taking on too much risk ○ “Don’t design for perfection – design to anticipate adjustment” Transact<-X--------->Relation X PD5. Reinvention of state role from funder to regulator (7) ○ Conduct site inspections ○ Be the record-keeper and tracker, alleviating capacity concerns Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<-----X----->Relation X X PD1. Formal meetings/calls/working groups, cross-sector (8) ○ Always been meetings, but “new element to these is consensus” ○ Non-contracting structures/ “speed dating” Transact<X---------->Relation X PD2. Use contracting process and clear provisions to achieve mission goals (17) ○ Protect access to care and ensure that “everyone gets paid” ○ Risk sharing and functional amendment process Transact<-----X----->Relation X PD3. Stakeholder engagement in policy (8) ○ High level and frequency of communications ○ Capitalizing or aligning on similar motivesa Transact<--X-------->Relation X PD4. Adaptive learning process (5) ○ Thorough and ongoing reviews to protect providers from taking on too much risk ○ “Don’t design for perfection – design to anticipate adjustment” Transact<-X--------->Relation X PD5. Reinvention of state role from funder to regulator (7) ○ Conduct site inspections ○ Be the record-keeper and tracker, alleviating capacity concerns Note: The number of unique examples offered by individuals is represented in parentheses after the strategy. aThere were two voices of agreement and two of dissent regarding whether similar motives existed, though all mentioned importance of alignment Open in new tab Table 4. Policy Development Strategies Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<-----X----->Relation X X PD1. Formal meetings/calls/working groups, cross-sector (8) ○ Always been meetings, but “new element to these is consensus” ○ Non-contracting structures/ “speed dating” Transact<X---------->Relation X PD2. Use contracting process and clear provisions to achieve mission goals (17) ○ Protect access to care and ensure that “everyone gets paid” ○ Risk sharing and functional amendment process Transact<-----X----->Relation X PD3. Stakeholder engagement in policy (8) ○ High level and frequency of communications ○ Capitalizing or aligning on similar motivesa Transact<--X-------->Relation X PD4. Adaptive learning process (5) ○ Thorough and ongoing reviews to protect providers from taking on too much risk ○ “Don’t design for perfection – design to anticipate adjustment” Transact<-X--------->Relation X PD5. Reinvention of state role from funder to regulator (7) ○ Conduct site inspections ○ Be the record-keeper and tracker, alleviating capacity concerns Collaboration Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<-----X----->Relation X X PD1. Formal meetings/calls/working groups, cross-sector (8) ○ Always been meetings, but “new element to these is consensus” ○ Non-contracting structures/ “speed dating” Transact<X---------->Relation X PD2. Use contracting process and clear provisions to achieve mission goals (17) ○ Protect access to care and ensure that “everyone gets paid” ○ Risk sharing and functional amendment process Transact<-----X----->Relation X PD3. Stakeholder engagement in policy (8) ○ High level and frequency of communications ○ Capitalizing or aligning on similar motivesa Transact<--X-------->Relation X PD4. Adaptive learning process (5) ○ Thorough and ongoing reviews to protect providers from taking on too much risk ○ “Don’t design for perfection – design to anticipate adjustment” Transact<-X--------->Relation X PD5. Reinvention of state role from funder to regulator (7) ○ Conduct site inspections ○ Be the record-keeper and tracker, alleviating capacity concerns Note: The number of unique examples offered by individuals is represented in parentheses after the strategy. aThere were two voices of agreement and two of dissent regarding whether similar motives existed, though all mentioned importance of alignment Open in new tab The strategy that was mentioned most often, which we label “fostering collaboration,” is further broken down into the collaborative relationships being built. Notably, the state does not limit itself to fostering collaboration in contractual relationships it is a part of; instead, it views itself as an enabler and convener across the policy field. Small providers are encouraged to find synergies (up to and including the point of formal merger), and embedded liaisons from other sectors are required in order to foster collaboration. Further, the creation of bodies such as the Regional Planning Consortiums are collaborative across both sectors and levels of government, where inter-organizational tensions can be just as high. There are five strategies used by government agencies in the formation of policy in the MMC context; these are predominantly process-oriented and displayed in table 4. The time-worn strategy of formal meetings was mentioned often, though with the new twist that building consensus is now a feature of the governance process. The crown jewel of these traditional bodies was the Medicaid Redesign Team, where interviewees mentioned the “new” consensus element and the diversity of sectors and interests in the room. There are also more informal versions of meetings designed to be spaces outside of formal contracting workshops; these meetings, referred to as “speed dating” by two interviewees, exist to facilitate the development of familiarity and congeniality among members of the MMC context. This addition of collaborative elements also extended to the deliberate inclusion of stakeholder engagement in policy, though there was disagreement between agencies on whether everyone’s motives were aligned. This likely underscored the third policy strategy: using the contracting process and clear provisions to achieve broad mission goals, such as protecting access to care and making sure that “everyone gets paid.” The fourth strategy retreats from this transactional space a bit to emphasize that this is an adaptive learning process that should not “design for perfection.” Finally, the state was preparing to transition from the role of direct funder and regulator to the more limited role of regulator only. Though there will likely still be some state-sourced funding that flows through the counties, the inclusion of the plans means that maintenance of the funding flow will no longer be the responsibility of the state. There was both relief and concern here: the state can now more fully concentrate on whether the public’s needs are being met effectively, but it also disrupts the more traditional bi-lateral funding relationships. Future study of the tensions involving accountability structures and information flow in this new environment will be warranted. Table 5 contains the four strategies that involved implementing the MMC policies rather than anticipating or developing them. These are all both anticipatory and built on the need for effective communication. The first, though focusing on communications within an organization, suggests that letting the operational details be handled by collaborative teams frees up the upper management to serve as a moderator. Though this role of shepherd watching the flock is reminiscent of classical top–down contract management, the need for communication within that top management team still exists and relies on effective collaborative work on the operational levels. Those cross-sector relationships and communication are the focus of the second and third strategies in table 5, with the need to harmonize outcome measures and metrics playing a key role. The focus of coordination being reduced down to the individual magnifies the coordinative needs of the plans, providers, and State, which have decades of trial and error on claim-based payments to learn from. Even without turbulence (which alone requires more sailors on deck to work the sails), the increased coordinative needs of the MMC context have provided additional pressures on coordination and communication. Table 5. Implementation Strategies Collab Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<--------X-->Relation X IM1. Focus executive leadership discussion on preparation for changes (5) ○ Set an example as moderator/leader ○ Keep watch for systems change Transact<----------X>Relation X X IM2. Rely on inter-organizational, person-to-person relationships (11) ○ “Focus on relationships” ○ Coordination around individual service recipients Transact<--------X-->Relation X IM3. Rely on constant multi-sector communication to monitor outputs and outcomes (5) ○ Bring plans and providers together around metrics rather than developing different ones internally ○ “Trust building” and monitoring through common tool usage and hosting meetings for people of same level across agencies and organizations Transact<----------X>Relation X X IM4. Serve as advocates for service recipient populations and the organizations which serve them (13) ○ Decrease state red tape and conduct patient/population advocacy against Department of Health, when necessary ○ Leveraging good interagency relations to protect providers versus ○ Maintaining a uniform opinion through the state agencies in meetings with other sectors Collab Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<--------X-->Relation X IM1. Focus executive leadership discussion on preparation for changes (5) ○ Set an example as moderator/leader ○ Keep watch for systems change Transact<----------X>Relation X X IM2. Rely on inter-organizational, person-to-person relationships (11) ○ “Focus on relationships” ○ Coordination around individual service recipients Transact<--------X-->Relation X IM3. Rely on constant multi-sector communication to monitor outputs and outcomes (5) ○ Bring plans and providers together around metrics rather than developing different ones internally ○ “Trust building” and monitoring through common tool usage and hosting meetings for people of same level across agencies and organizations Transact<----------X>Relation X X IM4. Serve as advocates for service recipient populations and the organizations which serve them (13) ○ Decrease state red tape and conduct patient/population advocacy against Department of Health, when necessary ○ Leveraging good interagency relations to protect providers versus ○ Maintaining a uniform opinion through the state agencies in meetings with other sectors Note: The number of unique examples offered by interviewees is represented in parentheses after the strategy. Open in new tab Table 5. Implementation Strategies Collab Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<--------X-->Relation X IM1. Focus executive leadership discussion on preparation for changes (5) ○ Set an example as moderator/leader ○ Keep watch for systems change Transact<----------X>Relation X X IM2. Rely on inter-organizational, person-to-person relationships (11) ○ “Focus on relationships” ○ Coordination around individual service recipients Transact<--------X-->Relation X IM3. Rely on constant multi-sector communication to monitor outputs and outcomes (5) ○ Bring plans and providers together around metrics rather than developing different ones internally ○ “Trust building” and monitoring through common tool usage and hosting meetings for people of same level across agencies and organizations Transact<----------X>Relation X X IM4. Serve as advocates for service recipient populations and the organizations which serve them (13) ○ Decrease state red tape and conduct patient/population advocacy against Department of Health, when necessary ○ Leveraging good interagency relations to protect providers versus ○ Maintaining a uniform opinion through the state agencies in meetings with other sectors Collab Type . Strategy Type . Strategies . Sub-strategies and Examples . Transact<---------->Relation . Cross-Sect . Within-Sector . Within-Org . . . Transact<--------X-->Relation X IM1. Focus executive leadership discussion on preparation for changes (5) ○ Set an example as moderator/leader ○ Keep watch for systems change Transact<----------X>Relation X X IM2. Rely on inter-organizational, person-to-person relationships (11) ○ “Focus on relationships” ○ Coordination around individual service recipients Transact<--------X-->Relation X IM3. Rely on constant multi-sector communication to monitor outputs and outcomes (5) ○ Bring plans and providers together around metrics rather than developing different ones internally ○ “Trust building” and monitoring through common tool usage and hosting meetings for people of same level across agencies and organizations Transact<----------X>Relation X X IM4. Serve as advocates for service recipient populations and the organizations which serve them (13) ○ Decrease state red tape and conduct patient/population advocacy against Department of Health, when necessary ○ Leveraging good interagency relations to protect providers versus ○ Maintaining a uniform opinion through the state agencies in meetings with other sectors Note: The number of unique examples offered by interviewees is represented in parentheses after the strategy. Open in new tab Communication also plays a role in the final strategy, though it does so in a way distinct from the other strategies included in the analysis. Throughout the interviews, employees of NYS often spoke of themselves in terms of the sector—they viewed themselves as agents of a unified NYS. One of the interviewees from the Department of Health remarked on the importance of promoting this sense of a unified front and uniform opinion when working with other sectors. However, this was not always the case with interviews from other NYS agencies. Some of those respondents spoke of leveraging good relationships with the Department of Health to protect providers, whereas others viewed advocacy on behalf of their service recipients and against the Department of Health to be a necessary element in their role in the MMC context. Strategy Type Our second research question for this study involved whether the strategies used to navigate policy turbulence were cross-sectoral. In classifying the 99 examples and 12 strategies that emerged, we created three categories. The first was cross-sector strategies, which means that the strategy was designed to involve multiple sectors (government, nonprofit, and/or for-profit). We also wanted to differentiate between within-sector collaboration between organizations, such as two state agencies working together, and strategies designed to impact only the state agency in which they originated. This was not a division that was originally planned for, but an important one that emerged from the interviews and the discussion on turbulence of scale. Between organizations in the same sector we refer to as inter-organizational, and strategies that stay housed within a single organization are labeled intra-organizational. In general, all three process stages have a mix of strategy types. In the capacity-building phase, technical assistance is delivered across sector boundaries, though the interactions can be both reciprocal and repeated. Reallocation of resources happens within the state, though this example of what Ansell and Trondal (2018, 48) would call “institutional syncretism” occurs both within and between agencies and involves both human and financial capital. Fostering collaboration occurs between sectors and organizations. Though some of these initiatives are designed to serve a particular function and then phase out (such as encouraging mergers among small providers), many of these capacity-building collaborations were designed for an indefinite and repeated learning cycle, such as the embedded liaisons. These permanent living sources of knowledge help to reduce uncertainty by expediting the sharing of information across sectors. The policy development phase consists primarily of cross-sector collaboration with an emphasis on shared understandings and aligned motives. Perhaps as a result of the degree of cross-sector strategies, policy development is also the phase with the keenest appreciation for the impact of time, with special attention being given to making sure that processes such as risk review and functional amendments are smooth, not perfect. The important shift of the state from funder to regulator, though an intra-organizational change, is certainly one that will have external effects. The majority of the implementation strategies are also cross-sectoral, with the sole exception being the increasing reliance of executive leadership on their staff to handle implementation and leave them free to handle systemic changes. This emphasis on cross-sector strategies is likely a reflection not only of the need to rely on each other for metrics like outcomes monitoring, but also the potentially adversarial role of one state agency versus another on behalf of a service recipient or provider. Even the relatively common goal of helping providers get through red tape still has the potential to cause conflict between the assisting agency and the one who installed the red tape in the first place. This is why communication structures are so crucial in a situation with extensive turbulence of scale, such as MMC. The Transactional-Relational Continuum Finally, to answer the third research question, we analyzed where on the transactional-relational governance continuum each strategy would fall. The transactional-relational governance continuum conceptualizes a broad range of inter-organizational contracting linkages that move between two poles anchored by transactional principal-agent interactions at one end and relational interactions at the other (Saidel 2011, 2017). The primary characteristics of a principal-agent relationship are asymmetric information and potentially divergent goals between the principal (government agency in this analysis) and agent (nonprofit organization) that result in the principal’s need to provide incentives or establish significant monitoring procedures to curb opportunistic behavior by the agent. By contrast, relational contracting features interactions between contracting actors that are collaborative, flexible, non-adversarial, mutual problem solving, and characterized by trust and frequent communications. Elements of both kinds of relationships are often apparent in the same set of inter-organizational linkages that are sometimes closer to the transactional end of the continuum and, at other times, closer to the relational end. Though we anticipated the continued reliance by at least some public contract managers on strong principal-agent interactions, we were much less confident about the incorporation of cross-sector strategies into public administrators’ management approaches. More recent studies on relational contracting have been more normative than empirical (e.g., Bertelli and Smith 2010; an exception is Fernandez 2007). What we found was that, unlike the strategy type, there was a strong relationship between the process stage and where the strategy fell on the transactional-relational continuum. The three strategies in the capacity-building stage are mixed: both within- and between-sector activities exist, but much of the infrastructure and skill development is delivered in a top–down fashion. The exception is fostering collaboration across the many different actors. Strategies such as designating liaisons and helping find synergies between providers that can form the basis for mergers are more relational. This blend is in contrast to the policy development phase, where most of the strategies are highly transactional. This is likely due to the nature of the activity since policy development is dominated by the creation of legal structures and enshrinement of power and responsibility. Not only is the actual policy formulation by the large group of stakeholders transactional, but so is the focus on operational elements such as ensuring continuity of care for service recipients or payments for providers. They are cross-sectoral and empowering to stakeholders, but the focus is on the content of the legal vehicle. The implementation phase, however, is very relational. Relationships between people are paramount, and there is evidence of both friendly and adversarial elements. There are even contradictions, where some consider the show of a unified state mentality to be important, whereas others freely admit that they will challenge the role of the Department of Health to protect the interests of service recipients or providers, with one state interviewee going so far as to use the phrase “my agencies” during the interview to refer to providers. We suspect that the state needs flexibility and human connection in order to keep these structures going. This applies not only to cross-sector relationships but also to the complex human network between NYS agencies with different mandates. Discussion and Theory Building This study set out to document and explain the presence of collaborative, multi-sector contracting relationships rooted in recent literature on the subject. What we found, however, was both more nuanced and reflective of earlier contributors to theory, such as Cooper (2003). Strategies that dealt with tasks that required adaptiveness, such as those involved with implementation, were highly relational and predominantly multi-sector. This is in line with the predictions of Johnston and Romzek (2008) and Romzek et al. (2014) that turbulent policy conditions would call for collaborative strategies. However, this was not our most interesting finding nor the most impactful for theory-building. Let’s turn instead to how the strategies we found did not meet our expectation of multi-sector, relational approaches. Rather than simply falling short of the collaborative mark, we found that the strategies varied in their attributes in a systematic way. This was not altogether unexpected due to the importance of environmental influences on contracting found by Van Slyke (2007) and Saidel (2011, 2017). However, neither author suggested that such variation could be attributable to a deliberate process of assembling a variety of strategies in an overall portfolio approach. We believe that this approach has an empirical basis with this study based on the links documented between strategy attributes and their purpose. Most notably, the strategies used by state agencies varied based on the stage of the contracting process. This is illustrated in figure 1, which maps each of the 12 strategies according to their location on the transactional-relational continuum (x-axis) and the scope of stakeholder involvement in decision-making (y-axis).13 The strategies are all labeled by the abbreviations found in the tables; for example, the second Implementation strategy is IM2. Though all three stages are predominantly multi-sector, each has at least one strategy that involves a within-organization or within-sector approach. More notably, however, is that the capacity-development strategies tend to be highly transactional and the implementation strategies highly relational, with the policy development strategies generally falling on the spectrum between the two poles. This suggests that there is something about the phase which helps to determine the appropriate strategy characteristics, a conclusion also drawn by Beinecke and DeFillippi (1999) in their study of Medicaid Managed Care policy implementation fluctuations in the state of Massachusetts. This interrupts what can be interpreted as the steady progression of the literature toward the assumption that greater policy turbulence universally generates more collaboration; rather, it appears to impact the overall portfolio of strategies rather than each strategy individually. Figure 1. Open in new tabDownload slide Characteristics of the Strategy Portfolio in the Medicaid Managed Care Policy Context. Each strategy is identified by the first letter of its contracting process stage (Capacity-building, Policy Development, or Implementation) and the number representing the sequence in which it appeared in the associated process stage table. For instance, IM3 is the third strategy listed in the Implementation Strategies table. Figure 1. Open in new tabDownload slide Characteristics of the Strategy Portfolio in the Medicaid Managed Care Policy Context. Each strategy is identified by the first letter of its contracting process stage (Capacity-building, Policy Development, or Implementation) and the number representing the sequence in which it appeared in the associated process stage table. For instance, IM3 is the third strategy listed in the Implementation Strategies table. This is also counter to the general normative assumption that more collaboration is always preferable to less. For example, this study finds that almost all capacity-building strategies save for the one designed explicitly to facilitate collaboration are transactional. This is because the development and administration of capacity-development programs, in this case, involves the sharing of resources from a well-resourced partner, albeit for long term gain of all parties. But the nature of the relationship in this context has a transactional basis due to this existing imbalance. Is this suboptimal, or is it simply a reflection of the dynamics of this portion of the contracting phase? Instead of suggesting a unipolar goal of making all contracting strategies more collaborative, we suggest that the mix of contracting relationships in a given policy scenario functions more like a portfolio. Due to the different objectives, relative strengths, and mechanisms involved in each strategy, the number of participants and their interactions will vary. Some of these strategies may be highly transactional, especially in the case of resource shifts or capacity development (though perhaps with participatory components, since few contracting parties would welcome unwanted or unnecessary capacity development). Conclusion Collaboration in public governance is a theme with a rich literature in many areas of public management. A notable exception has been in contracting, with the number of studies dedicated to collaborative relations internal to the contracting process fewer in number. This gap persists despite both the prevalence of contracting in delivering services to the public and the appearance of useful tools such as continua by the authors active in the research space. This study contributes to the theoretical underpinnings of collaboration in contracting by fusing these recent conceptual devices in collaborative contracting research with the lived experiences of those navigating the environmental turbulence of Medicaid Managed Care for children’s services. In addition, it enriches the well-developed theme of environmental turbulence by identifying elements of turbulence in a specific policy context that are associated with particular types of public management strategies. Using 21 unique perspectives from experts in the policy environment, we distilled 12 overall strategies employed by government agencies to manage the turbulence of the Medicaid Managed Care context. These were grouped according to the stage in which they were used: capacity-building, policy design, and implementation. Each stage had a mix of strategies used across sector boundaries, in addition to ones used within the same sector (within-sector) or the same organization (within-organization). This finding adds empirical evidence to the predominantly conceptual studies in the literature which predict substantial use of cross-sector collaboration in periods of turbulence. However, we do find that certain stages tend to be more transactional than relational, which suggests that the high need for cross-sector strategies may not imply a diminished concurrent reliance on more traditional command-and-control approaches. Rather, a more nuanced and now empirically supported analysis of contracting dynamics demonstrates that, under certain conditions, public management strategies, especially in the implementation stage of the policy process, shift significantly toward the relational end of the public governance continuum. These conditions, consistent with a number of dimensions of turbulence posited by Ansell and Trondal (2018), include persistent policy turbulence and the prolonged uncertainty it triggers, expansive scope and scale of change, unusually complex, often structural nature of the change underway, and intermittent periods of an accelerated pace of change. The strategies operationalized under these conditions reflect the multi-sector interdependence that characterizes much of public governance today. At the same time, within-sector intra-organizational and inter-organizational approaches do not entirely disappear. The New York State MMC environment provided an ideal research setting in which to examine the impact of turbulence on contracting strategies. Although the study was conducted in a single state, New York is a state that is remarkably diverse in demographics, geography, rural, suburban, and urban areas, and regional cultures. Its government-nonprofit ecosystem is dense and anchored in a rich history characterized by long periods of relative stability and only occasional disruptions. In contrast to some states, counties are major players in the human services arena. The study reported here provides empirical evidence of the validity of Ansell and Trondal’s (2018) theoretical framework, especially the association between turbulence and interdependence and turbulence and collaborative governance. At the same time, our findings enrich the framework by (1) adding the notion of a prolonged period of policy uncertainty to the dimension of temporal complexity and (2) identifying specific strategy choices that public agencies utilize at different points in the policy process to navigate periods of policy turbulence. The continued evolution of the Medicaid Managed Care policy environment and other similar scenarios underscores how important continued research is in this area. This applies to both theory development and empirical testing. For example, though this study included triangulation from multiple sectors, the focus was primarily on state actors. Complementary studies from the health plans and providers would be interesting, particularly as the policies are deployed and researchers can watch for strategy shifts between stages in the contracting process. Further, comparative work on the policy contexts of different states and different levels of government would be enlightening. Acknoweldgement The authors would like to acknowledge Roland Poirier, David Van Slyke, Kimberly Wiley, and three anonymous reviewers for their insightful advice and comments. Funding This work was supported by the Three Voices Grant Program at the University at Albany Emeritus Center. Appendix 1: Interview Protocol (State Agencies) 1. To begin, we have some informational questions. What is your current job title? 2a. How long have you held this position? 2b. How long have you worked in this agency? 3. Have you ever worked or volunteered for a nonprofit organization? If yes, in what capacity? 4. Do you currently or have you in the past served on the board of directors of a nonprofit? 5. Now let’s change the focus to the current climate of policy uncertainty in Medicaid managed care. What is the agency’s role in this new landscape? Would you please describe what strategies ____ [agency name] is relying on to manage the contracting process and contracting interactions with both the plans and the providers in this period of uncertainty? What language would you use to describe the kind and scope of this change? If the new system is working really well, what will it look like? What are the principal barriers that might prevent the new system from working well? 6. Now think about other periods of policy change in which you have been involved. Would you say that the strategies you just described are similar to or different from strategies utilized by __________ [agency name] in earlier periods of change? Please be as specific as possible. 7. Given the reality that contracting for services is the predominant mode of public governance in the human services sub-sector, we are particularly interested in whether and how public managers’ strategies reflect cross-sector interdependence with both the plans and nonprofit providers. Would you characterize the strategies you have described as cross-sector strategies? If so, what are the key cross-sector elements of the strategies? 8. What would be the most helpful things for the nonprofits and the plans you work with to do in order to navigate successfully through this period of policy uncertainty? 9. Finally, who else in the agency or other agencies would you recommend that we speak with in order to deepen our understanding of the issues we’ve discussed? Appendix 2: Interview Protocol (Experts) 1. To begin, we have some informational questions. What is your current job title? 2a. How long have you held this position? 2b. How long have you worked in this company? 3. Have you ever worked or volunteered for a nonprofit organization? If yes, in what capacity? 3a. Have you ever worked for a county or state government agency? 4. Do you currently or have you in the past served on the board of directors of a nonprofit? 5. Now let’s change the focus to the current climate of policy uncertainty in Medicaid managed care. f. What is the role of the state agencies in this new landscape? What about the counties? g. What is the role of the nonprofit providers in this new landscape? h. What is the role of the Plans in this new landscape? i. Would you please describe what strategies these different players are relying on to manage the contracting process and contracting interactions in this period of uncertainty? j. What language would you use to describe the kind and scope of this change? k. If the new system is working really well, what will it look like? l. What are the principal barriers that might prevent the new system from working well? 6. Now think about other periods of policy change in which you have been involved. Would you say that the strategies you just described are similar to or different from strategies utilized by these players in earlier periods of change? Please be as specific as possible. 7. What would be the most helpful things that the state, counties, plans, and nonprofit providers could do to ensure that the contracting system works well during this period of policy uncertainty and profound change? 8. Finally, who else in your networks would you recommend that we speak with in order to deepen our understanding of the issues we’ve discussed? Footnotes 1 See, for instance, Agranoff 2006; Amirkhanyan, Kim, and Lambright 2010; Amirkhanyan, Kim, and Lambright 2012; Bertelli and Smith 2010; Lamothe and Lamothe 2012; McGuire 2006; Milward et al. 2010; Romzek, LeRoux, and Blackmar 2012. 2 Milward and Provan (2003) and Heinrich, Hill, and Lynn (2004) made a similar observation about the existence of both vertical and horizontal dimensions in the context of network management. 3 This insight echoes Romzek and Johnston’s (1999) finding in a study of the implementation of Medicaid managed care in Kansas that “The weakest link in the implementation process appears to be the lack of collegial working relationships between the contract monitors and the contracting agency directors and case managers” 136). 4 Saidel (2011, 2017) originally labeled the poles of the continuum “governance by proxy” and “governance by partnership.” The labels modified terms used in Kettl’s (1988),Government by Proxy and Salamon’s (1987)“Partners in Public Service: The Scope and Theory of Government-Nonprofit Relations.” 5 Earlier scholars Mcneil (1978) and Beinecke and DeFillippi (1999) posited a formal, linear contracting continuum ranging from classical to relational, legally-based interactions. 6 Other studies that emphasize the dynamic nature of contracting relationships are Cho and Gillespie (2006) and Alexander and Nank (2009). 7 In an earlier study, Milward and Provan (2003) use the term “collaboration” to refer to service integration and coordination to achieve a continuum of care among otherwise competitive social services network partners. 8 There was a single exception to the recording and transcription in accordance with the interviewee’s wishes. During this interview, extensive field notes and memoing documented the responses, which included direct quotes. 9 In 2008, managed care in the United States covered 70% of the Medicaid population (Kim and Jennings 2012). 10 New York State provides model contracts for guidance on Primary Care Partial Capitation, Medicaid Advantage, and HIV Special Needs Plans (NYS Department of Health 2019b). Beyond these are numerous contracts and subcontracts associated with the MMC environment that are varied in number, nature, and type of signatory. 11 Fee-for-service refers to a system in which a contracted provider receives payment when a particular service is delivered. 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TI - Public Agency Strategies, Collaborative Contracting, and Medicaid Managed Care
JF - Perspectives on Public Management and Governance
DO - 10.1093/ppmgov/gvaa011
DA - 2020-08-27
UR - https://www.deepdyve.com/lp/oxford-university-press/public-agency-strategies-collaborative-contracting-and-medicaid-L6hcnqcfC8
SP - 239
EP - 255
VL - 3
IS - 3
DP - DeepDyve
ER -