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Street sweeping in D.C. was a disaster. Like most cities, D.C. had parking rules that banned on-street parking on street sweeping days. A lot of people ignored the rules because they learned they could get away with it. Historically, parking control officers in D.C. could only cover roughly 20 percent of the street sweeping routes, meaning most scofflaws got away with parking illegally.

Cars blocking the sweepers are bad news. For every car along its route, a sweeper misses at least three spaces worth of street -- meaning all that dirt and grease wind up in the Potomac.

Hiring enough ticket writers, or using police, is simply prohibitively expensive. Residents had learned that in general the District's sweeper-day parking rules were on the books but were almost never enforced. What could the District do?

Enter the District's high-tech superhero: Sweepercam, the creation not of DC Comics but the D.C. Department of Public Works. By equipping each street sweeper with a digital camera, drivers are now able to simply snap a photo of the license plate of an illegally parked vehicle. Using high-tech license plate recognition software, the city then automatically generates and mails out parking citations to owners. A Global Positioning System includes a precise location of each ticketed vehicle, as well as a digital photo. Instead of getting away with it, anyone who parks along a sweeper lane now gets a ticket.

"Sweepercam has been very effective at keeping the curb lane clear so our vehicles can make a clean sweep," said DPW Director William O. Howland. Thanks to Sweepercam, Howland says, "we will be ticketing the vehicles that are parked illegally and keeping the sweepers from doing their job."

Like many cities, Washington, D.C., is dominated by impervious surfaces such as roads, rooftops and parking lots. When it rains, the District's stormwater flows directly into local streams and rivers.

Those hulking yellow beasts with their whirring brushes suck up not only dirt and trash, but nasty pollutants such as oil and grease (ten pounds per mile swept) and phosphorous and nitrogen (three pounds per mile swept). Left on the street, rain washes these 'nasties' into the Potomac and Anacostia rivers, and from there to the ecologically-fragile Chesapeake Bay.

The District of Columbia appears to be the first city in the nation to merge the high-tech with altered backend processes to completely reengineer the way street sweeping and the associated ticketing process is managed. The mash-up of these two related but independent functions creates a "superhero" program that other jurisdictions are now starting to look at.

It won't be easy, however, as Sweepercams may require changes to the law. In fact, D.C. needed to change its parking ticket law to make it legal to use the Sweepercams. According to the Pittsburgh Tribune-Review, Pittsburgh is considering installing cameras on its sweepers, but doing so may require changes to both state and municipal law.

In Chicago, a recent initiative to install cameras on street sweepers has been abandoned due to legal issues, reports Streets and Sanitation spokesman Matt Smith in the Chicago Sun-Times: "To get the desired results consistently, we need to pair our camera technology with higher-tech signage that will work in conjunction with the cameras to confirm our data so that it can stand up in a hearing." There were also some "big brother" privacy concerns with the Chicago program.

Though ground-breaking in its application, the underlying technology of license plate recognition is well proven. In London, vehicles are charged a special fee for driving downtown during business hours. Beginning in 2003, London's program used cameras mounted around the zone to capture the license plates of vehicles entering the charging zone in order to make sure they had paid their fee.

As the trend toward digital innovation advances (see, Phone + GPS + Camera = Revolution) expect to see more Sweepercam mashups that employ high-tech solutions to mundane problems -- with potential superhero results.

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Professor Stephen Goldsmith of Harvard’s Kennedy School of Government has been tapped by Mayor Michael Bloomberg to serve as New York’s Deputy Mayor of Operations, essentially the number two spot in city government. Said the mayor at the press conference introducing his pick: “Lots of people talk about reinventing government; I think it’s fair to say Steve has actually done that.” Goldsmith served for two terms as mayor of Indianapolis, and is credited for successfully launching a citywide competition initiative.

Mayor Bloomberg has been committed to innovation, introducing shakeups in the city’s 311 system and school administration. New York City will need more innovative thinking going forward, as the city faces a looming $5 billion budget gap. Goldsmith will oversee some 12 city agencies, including police, fire, transportation and sanitation.

The innovation group at the Ash Center will continue to follow the latest trends in public sector streamlining. Stephen Goldsmith, while on leave from Harvard, will continue to contribute and we wish him the best in his new undertaking.

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For example, a state that drops dental care for adults may well see a rise in emergency room visits for dental emergencies and/or an increase in medical conditions that are linked to poor oral health.  A program that cuts optional personal care services will likely experience an expensive increase in institutionalizations.

From firsthand experience as Indiana’s Medicaid director, I know that being in the driver’s seat of a state Medicaid agency when the budget calls for substantial cuts is a daunting proposition. Thoughtful analysis of potential long-term implications can help Medicaid programs prioritize proposed cuts. Looking to where the bulk of Medicaid dollars are spent can be tremendously helpful in making decisions about where to trim first.

In every state, a small percentage of extremely high-need patients account for the biggest share of Medicaid spending. Nationally, under five percent of Medicaid beneficiaries account for nearly 60 percent of total program costs. In the long run, providing better, more strategically managed care is critical to containing costs. Indeed, over time, eliminating duplicate services and reducing fragmentation of services for these high-need patients should generate savings in many cases.

Opportunities that Medicaid cannot afford to ignore – what my organization, the Center for Health Care Strategies (CHCS), has labeled Medicaid Best Buys – are detailed below. These are areas where Medicaid can potentially get the most “bang for the taxpayer buck,” where investments in better managing care can both improve people’s health and reap the greatest return. Potential Medicaid Best Buys for states include:  

·         Care Management for High-Risk Pregnancies -- Medicaid covers more than 40% of the newborns in the US, with births accounting for a significant percentage of total Medicaid inpatient admissions. Hospital costs for a healthy newborn average $1,500, compared to $79,000 per stay for a low birth weight infant in the neonatal intensive care unit (NICU). Innovative state and health plan programs that identify women in high-risk pregnancies and intervene with tailored prenatal programs have helped reduce the number of infants that need intensive care. For example, one health plan in New York State improved its prenatal outreach program for Medicaid members, thereby reducing NICU days and saving an estimated $2 for every dollar invested in the program. Avoiding a NICU stay for even one newborn can potentially save millions, and more important, can give a baby a much healthier start in life.

·         Care Management for Children with Severe Asthma – For most states, asthma is one of the leading causes of emergency room visits and hospital admissions for children covered by Medicaid. Roughly 12 percent of children in Medicaid are diagnosed with asthma, with health care costs estimated at more than $16 billion annually. Care management programs that target children with severe asthma can reduce dangerous flare-ups, keep children away from emergency rooms and hospital inpatient stays, potentially saving substantial dollars. Arkansas’ Medicaid program, for example, focused an intensive nurse case management program on a small group of children with severe asthma. Preliminary findings suggest that the state saved more than $6 for every $1 invested in the program.

These first two “Best Buys” can offer states shorter-term returns on program investments, by shortening or avoiding stays in intensive care units for newborns and reducing frequent emergency room and inpatient visits for children with asthma. States can invest potential savings from these efforts into programs to improve care for more complex needs populations that offer significant longer-term payoffs, including:

·         Managed Care for Aged, Blind, and Disabled Medicaid Beneficiaries –

Medicaid beneficiaries with disabilities under age 65 – who are among the aged, blind, disabled, or ABD, population – have a complex array of health as well as psychosocial needs and are among the program’s costliest patients. Most have multiple chronic physical and behavioral health conditions, yet the vast majority of these patients still receive their care in a piecemeal fashion through fee-for-service care. The result is poorly coordinated, inefficient, and often, unnecessarily expensive care. A number of innovative states are piloting new systems of care to better align payment in ways that promote integration of physical and behavioral health services. Enhanced primary care management programs in states like North Carolina and Oklahoma are seeking to improve health outcomes and control excessive costs by identifying patients who are most likely to benefit from care management and designing strategies to address their specific needs.

States can also look for opportunities to focus more targeted “high-touch” care management programs on the relatively small number of Medicaid beneficiaries who account for a significant portion of overall program spending. Among the most expensive 1% of Medicaid patients, close to 90% have three or more chronic conditions and nearly 70% have five or more. States that design programs for the top 1-5% of the highest-need, highest-cost beneficiaries can potentially improve care and patient outcomes and reduce frequent emergency room visits, hospitalizations, and nursing home placements. Pioneering states, including Colorado, New York, Pennsylvania, and Washington are piloting new models to rethink care delivery and control spending for their highest-cost populations.

·         Integrated Care for Medicare-Medicaid Dual Eligibles – Adults who are dually eligible for Medicaid and Medicare (the "duals") are among the nation's most chronically ill and most costly patients, accounting for 46 percent of total spending within Medicaid and 25 percent within Medicare. Yet, the majority of the nation’s nearly nine million duals receive fragmented and poorly coordinated care with no financial alignment between Medicaid and Medicare services. Integrating health and long-term care and financing for these high-need beneficiaries offers an important -- and, largely untapped -- opportunity for states to improve care and rein in costs for both state and federal government. Finding ways to share these savings is currently a hot topic among state and federal policymakers. States, like New Mexico and Vermont, are exploring innovative opportunities via special needs plans and alternative models to integrate Medicaid and Medicare services and provide higher-quality and more cost-effective care.

Admittedly, these Best Buy strategies will not be a panacea for every state Medicaid agency grappling with severe budget cutbacks. There will still likely be difficult and painful cuts. But taking advantage of these opportunities offers a better long-term approach for strategically prioritizing both where to cut and where to invest.  Simply put, improving care for Medicaid’s most ill and most costly beneficiaries offers the greatest potential for states to curb spending and bend the health care cost trend.

Future columns will delve deeper into specific examples to showcase how innovative states are maximizing Medicaid dollars to improve outcomes and generate cost efficiencies in serving low-income Americans with complex health care needs.

Melanie Bella is senior vice president of policy at the Center for Health Care Strategies, a nonprofit that works with Medicaid stakeholders to improve the quality of publicly financed care. She previously served as Medicaid director for the State of Indiana from 2001-2005.

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According to a 2009 report from the Office of Management and Budget, benefit programs are rife with erroneous payments. The OMB found that the Medicaid error rate was 10.5 percent, totaling $18 billion in flawed payments. The Temporary Assistance for Needy Families welfare program error rate was 9.3 percent, and the State Children's Health Insurance Program was 14.7 percent. Without question, the opportunity exists to improve practices and squeeze out inefficiencies so that scarce resources benefit those in need.

Every day, federal and state authorities oversee programs that contain billions of dollars of waste, fraud and client inconvenience. Yet even during these dire fiscal times, far too few public leaders take on reforming these systems, wasting precious resources intended to help those truly in need.

Taking on embedded inefficiencies can produce big results. Consider just one improvement: converting to electronic distribution of benefits. Government has been expanding its use of plastic stored-value cards in recent years, but big opportunities still exist.

Oklahoma took on the challenge in 2003 when the state's Department of Human Services faced several child-care challenges.

The situation was difficult all around. Dollars were short, and the demand for child-care support exceeded the available resources, frustrating mothers who wanted to work but couldn't without some child-care help. In addition, child-care providers were frustrated by the slow and cumbersome paper-based reimbursement systems, prompting some providers to simply refuse to accept children in the program. Most critically, there was significant waste and a lack of financial accountability throughout the system, building in a tolerance for incorrect payments. Too many providers simply "rounded off" their bill, charging for 30 days even if the child attended for just 25.

Facing fiscal constraints, Oklahoma couldn't afford an expensive overhaul. What it needed was a simple, cheap solution. They found it in a system utilizing an Electronic Benefit Transfer program, a proven method of benefit disbursement that had already worked well with food stamps.

The EBT program employed time and attendance tracking to solve the problems the state's child-care system was facing. The department could now document and pay at the point of service while simultaneously verifying eligibility in real time — allowing them to pay providers for actual services provided and to eliminate retroactive paperwork and undocumented claims for payment.

Not only did the system provide a solution to exiting problems, it also dramatically enhanced the usability of Oklahoma's child-care service. Parents could now use a convenient card to check their child in and out of day care. Parents and providers would now be notified of coverage and co-pays through instant eligibility verification, and automatic payment calculations would be based on actual attendance — eliminating the need for invoicing paperwork. The plastic benefit cards were fast, accurate and paper-free.

State officials estimated that waste and fraud dropped by 10 percent, not a surprising number in light of the findings from OMB. Just imagine if 10 percent more poor moms nationwide could receive child-care assistance, with no increase in costs?

This all seems so obvious and yet is so overlooked. So what keeps government from racing to implement such reforms, whether in child care or school lunch or a host of other benefit programs? The sad fact is that many government officials are caught up in thinking that a "cut" means a program cut, and where the word innovation often entails unacceptable personal risk.

First of all, anything new puts a bull's eye on the backs of public officials. Routines, even flawed paper-based routines, entail no risk. Clever innovations involve change, and these innovations can be unrewarding for managers. After all, any departure from standard practices entails taking on vested interests and in many cases, fellow employees. A streamlining effort can be risky, especially if the transition is less than perfect.

Taking on fraud can sometimes go against an agency's "helping" culture, too. Bureaucrats often sincerely care about those they serve, and can't bear to inflict discomfort on anyone seeking help — fearing that these increased accountability systems will produce discomfort or stigma for applicants. Increasing the accountability through a card swipe system isn't mean however, since it can redirect limited resources to those most in need.

Rooting out inefficiency is tough work. It means implementing new technologies and constantly searching for ways to do things better, faster, cheaper. It's easier to throw up your hands and say, "We can't cut anymore," than to root out inefficiency and waste program by program.

The lesson here is simple: Instead of looking to explain what you can't do without, look hard at how you can make the most of what you've got. Doing so will create a culture that encourages innovation and protects those who advocate for innovations that increase accountability while improving results.