Author Archives: HITC Editor

Welcome to the 2019 State HIT Connect Summit!

States are coordinating major initiatives including data governance and interoperability, Medicaid modernization, MMIS re-procurement, HIX operations, payment reform, population health, program integrity as well as data privacy, security, and compliance issues at many levels.

At the same time, the shift towards modularity, SaaS and cloud computing are helping to shape IT organizations to be more responsive to the needs of policy and administration leadership. Emerging and potentially disruptive technologies such as blockchain and artificial intelligence are also being piloted in Medicaid which has the potential to yield benefits beyond process automation and interoperability and potentially underpin the next phase of HHS innovation.

The 2019 State Healthcare IT Connect Summit marks the 10th anniversary of the program. The conference has grown and evolved into an important national venue for public and private sector thought leaders to share ideas and benchmark implementation strategies of State Health IT Systems.

The meeting comprises keynotes, keynote panels, collaborative networking roundtables, workshops, focus groups, Connect Exhibition and breakouts assigned to 6 tracks (as below).

TRACK 1 | Medicaid Modernization, Modularity, and MMIS Procurement
TRACK 2 | State Innovation, Data Analytics and Population Health Management (including Opioid Abuse)
TRACK 3 | Enterprise Systems Planning, Health & Human Services Integration
TRACK 4 | Compliance, Security & Combatting Fraud, Waste & Abuse (including 3rd Party Liability)
TRACK 5 | State Marketplace Reform and Managed Care Optimization
TRACK 6 |Emerging Technologies Forum

Cross-cutting agenda themes include Data Quality, IT Service Management (focus on outcomes), Interoperability, Consumer Empowerment, Security and Compliance.

View Final Agenda | 2019 Speakers & Sponsors

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Mike Sasko , VP Government Solutions, Softheon, sat down with Healthcare IT Connect’s Rob Waters to discuss implementation of AVS across HHS agencies in a modular environment.

RW: As you engage with state teams across the country, many of whom are now implementing modular modernization strategies, what are you hearing from states regarding their planning efforts as it relates to the OPI (Office of Program Integrity) and their response to the CMS mandate?

MS: The CMS mandate known as SSA Section 1940 has indeed proven to be a game changer specifically for states required to deploy electronic Asset Verification Systems (AVS). Additionally, several states are passing their own add-on legislation to include for example SNAP as in West Virginia. Finally, states are discovering the economic benefits of executing many of these “front door” OPI initiative to include identity management, hard and soft asset verifications, SSN scanning and services to support child support and alimony claims as well as general audit and recovery.

RW: How is Softheon’s approach different in supporting AVS and what capabilities are you bringing to this market from other markets Softheon is engaged with?

MS: Our product is unique in that it is provided initially in portal delivery prior to a modular integrated solution for MMIS or state eligibility system. This approach allows states to be immediately CMS compliant while providing for integrations later into stable eligibility platforms – directly within current eligibility workflows. The portal approach allows for user interventions and testing well in advance of deployment as multi-agency stakeholders can configure product to best support shared state uses.

RW: - Of course AVS is a delivered through a partnership model, what does that look like for Softheon’s

MS: Depending on the specific data set requirements, Softheon’s partnership model allows for the use of several mostly credit bureau agency partners, all of which provide their unique data for our use. In most state deliveries we use two partners and will leverage any state contracts already in place – for example an identity management contract. As access to data continue to improve, we at Softheon are able to deploy new partners at significantly reduced prices. The days of a singular offering utilizing a singular data set are coming to a close. Technology advancements such as ours are allowing for truly modular AVS offerings at significantly reduced state costs.

RW: At this year’s conference there is a major focus on accountability and outcomes to HHS program objectives, what is Softheon doing to further demonstrate the accountability of your solution to the OPI and ultimately state legislatures?

MS: At HITC 2019, Softheon hope to share the message that OPI initiatives are multi-agency state initiatives. Medicaid as well as Human Services, Social Services, Recovery and IG all can play a role and all can share a platform. It’s about integrating into established workflows with each use agency to improve accuracy of their work and overall efficiency. States and state legislators continue to share that immediate access to verification data not only improves their workflows but allows for a better customer experience with state beneficiaries, who count of these safety net programs in their daily life.

RW: Any last feedback?

MS: Softheon is proud of our relationship with HITC and partner agencies. We appreciate the opportunity to present at this show and to share our story of “disrupting” within the OPI AVS segment – for the benefit of all stakeholders nationwide.

Softheon is the 2019 TRACK 4 Sponsor Security, Compliance, Combatting Fraud, Waste & Abuse | Attend Softheon Sessions
Track 5|  INDUSTRY SESSION – A Blueprint for States: Executing Medicaid Expansion and the ACA
Tuesday, March 19th • 2:45pm – 3:45pm

Track 4| West Virginia Asset Verification Services (AVS) journey to meet both CMS mandate and new state SNAP legislative requirements
Wednesday, March 20th • 1:30pm – 2:30pm

View 2019 State Healthcare IT Connect Final Agenda

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Optum completed more than 66,600 assessments in a nine-month period – with more to come – to help coordinate care for individuals with chronic, high-cost behavioral health, developmental, and long-term care needs. 

Jennifer Petersen Program Director, Optum State  Government Solutions, sat down with Healthcare IT Connect’s Rob Waters to discuss Improving Medicaid Outcomes, Reduce Costs.

RW: Can you explain the impetus behind these independent assessments?

JP: The Arkansas Department of Human Services (DHS) has ambitious goals to improve the State’s Medicaid program, including achieving more than $800 million in savings by 2021 through program efficiencies, improved utilization of services, and better outcomes. To accomplish this, a more comprehensive and coordinated effort is needed to manage the care of those beneficiaries with complex medical and behavioral health conditions.

RW: Who makes up the bulk of this population?

JP: Arkansas now spends about $2 billion annually on an array of Medicaid services for
150,000 people who have at least one claim for behavioral health, substance abuse disorder, or
developmental/intellectual disability (DD/ID) services. Within this group, the state is focusing aggressively on about 40,000 individuals with higher levels of need that account for about $1 billion in Medicaid spending. It is this group of people on which Optum has performed most of its functional assessments to
determine who needs what services – which ones, how many, and how often.

RW: How are these assessments used?

JP: The scoring from the assessment questions produces an initial “tier determination” for
beneficiaries, which is sent to the state for authorization of a specific level of services depending on need. Optum has provided these 66,000+ assessments across three DHS divisions: the Division of Aging and Adult Services (DAAS), the Division of Behavioral Health Services (DBHS), and Developmental Disability Services (DDS). Using a single tool enables more coordinated care for individuals with more than one issue – for example, clients with both mental health issues and developmental disabilities.

RW: What do the assessments entail?

JP: Optum assessments are “functional” rather than “clinical.” This means they cover a range of categories including an individual’s ability to engage in “activities of daily living (ADLs)” such as eating, bathing, dressing, and personal hygiene; whether they can prepare meals, or manage their own medications and finances; determinations of their memory and cognition; their ability to communicate; their ability to provide for their own safety and well-being; and issues related to depression, suicide, alcoholism, substance abuse, gambling, and many more.

RW: Does Optum determine care levels and care plans as part of these assessments?

JP: No. The State makes the ultimate decision on the type and level of care a beneficiary
will receive. Nor is Optum involved in any care-plan development decisions – those determinations are made by providers, the beneficiary’s care coordinator (who works for the PASSE), or the nurse who cares for the aged, all of whom receive the results of assessments.

RW: What does Optum deliver?

JP: Optum provides the comprehensive assessment tool; qualified professionals to objectively and reliably administer the tool; the underlying technology platform required to support the tool and collect and report data across population groups and programs; and provider training, support, and outreach.

RW: Optum conducted an extraordinary number of assessments in a short period of time – what was the key to this success?

JP: Like any broad-based program, we had some glitches at the beginning, but collaboration with the State and providers helped turn things around quickly. One of the key steps was to embed assessors at provider sites so they could conduct assessments as part of a patient’s regular visit for an exam, a consultation, to obtain a prescription, or conduct assessments at care facilities and institutions.

RW: Do providers have access to the results of the assessments?

JP: Yes, provider involvement is critical to achieve the State’s goal of improving outcomes and reducing costs. To coordinate care among this group, Arkansas DHS has established a unique model in which providers of specialty and medical services are entering into new partnerships with experienced organizations that perform the administrative functions of managed care. Together, these groups of providers and their managed care partners are developing new business organizations called Provider-Led Arkansas Shared Savings Entity (PASSE). Each PASSE is responsible for integrating physical health services, behavioral health services, and specialized home- and community-based services for individuals who need intensive levels of treatment or care. The assessments offer them a more complete view of their patients. This “embed” approach helped in numerous ways: It located assessors “where the beneficiaries were,” itmitigated – and virtually eliminated – the negative “telemarketer effect” that assessors would experience when they called beneficiaries at home; and it engaged providers in the process in a more active way.

RW: How did the “embed” approach improve results?

JP: Almost immediately, the number of assessments conducted leapt exponentially, from a low of around 30 per day to more than 500 per day – and sometimes as many as 700 daily – in about three months. More than 160 assessors were embedded at provider locations across the State and they “touched” 250 individual provider locations.

RW: What has been the reaction to the work?

JP: Not only was DHS pleased with the approach and the results, but anecdotally, Gov. Asa Hutchinson has also expressed his confidence in Optum, both to DHS leaders, and when the Governor had a chance encounter with one of the company’s assessors while she was having lunch in a small town. He complimented her on the company’s performance. We’ve also had positive response from providers, social workers, and beneficiaries and their families. They see the assessment approach paying dividends. They have confidence that the assessments will be conducted in a quality way.

RW: What’s next?

JP: Thousands of additional assessments are on tap for the near future, including behavioral health renewal assessments; ID/D pediatric assessments for children with significant development disabilities who need a care plan; and aging and personal care assessments. Working closely with DHS and providers, Optum is continuing to improve the process, constantly updating to reflect what assessors have learned as they’ve questioned beneficiaries and dealt with doctors, clinics, nursing homes, and other facilities. The Optum independent assessments are and will continue to be a critical component in the overall continuum of care for thousands of Arkansas Medicaid beneficiaries.

Optum is the 2019 TRACK 2 Sponsor | State Innovation, Data Analytics & Population Health Management

Attend Optum Sessions TRACK 3 | More than 66,000 Independent Assessments Help Arkansas Coordinate Care for Medicaid Beneficiaries with Chronic, High-Cost Needs Tuesday, March 19th • 4:00pm – 5:00pm

Track 2 | INDUSTRY SESSION  Moving Beyond “Health Care” to Address the Social Determinants of Health: How States Use Analytics to Gain a Broad View of Social Services and are Improving Outcomes

Tuesday, March 19th • 2:45pm – 3:45pm

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Tom Byrne, VP Government Solutions, sat down with Healthcare IT Connect’s Rob Waters to discuss how the emergence of patient-centered data design and what this means for states as they explore modular modernization strategies.

RW: The opening session for Track 3 (Enterprise Systems, H&HS Integration) introduces the concept of person-centered data design and how this approach enables states to integrate new data sources and advance community engagement, what should states be thinking about as they embark on such initiatives?

MS: Person-centered data design is predicated on rapidly integrating new sources of data and making it more easily accessible, and states should be thinking about how to accomplish this most easily. How do we build a 360 degree view of the person/member.? Traditional approaches require a significant amount of effort to both organize and fuse data together. This is primarily because data is persisted in legacy technology, often relational databases, where the structure and indexing of the data needs to be known prior to using it. Maintaining these rigid structures can be challenging as unforeseen business needs arise.
A modern approach is to leverage an integration platform that forgoes these challenges by leveraging a modern enterprise NoSQL database that easily accommodates unforeseen changes without sacrificing enterprise capabilities mission critical applications expect. It also enables the ability to query integrated data without needing to know the underlying structure or indexing, resulting in agility when querying, fusing, and reporting.

MS: It is this type of agility that has enhanced citizen services at the Maryland Department of Human Service. The Maryland Total Human-services Information Network, or MD THINK, is a cloud-based modernization initiative that breaks down traditional silos and data barriers between state agencies and provides integrated access to administered programs. MarkLogic serves as the foundation of the Shared Data Repository that supports data from legacy systems and new programs and applications being developed as part of their modernization effort. The ability to rapidly onboard and fuse new, unforeseen data sets is vital to this program.

RW: At the same time many states are exploring modular modernization strategies that will enable them to be more agile and cost-effective in supporting programmatic goals. How does this data model translate to supporting these goals, and what are some of the data architecture considerations in meeting them?

MS: Leveraging a modern integration platform supports the goals of modularity in a number of ways. The ability to load data sets “as-is” without upfront data modeling provides significant time (and thus cost) savings. Further, to be able to meaningfully query data without any prior knowledge of the structure or indexing of the underlying design is a powerful tool that promotes unparalleled agility; module developers are more quickly able to create applications without needing to be experts on the architecture of the database itself. Some of the architectural goals that should be considered would be to support data integration platforms that are trusted to run the business and that contain truly enterprise capabilities. Top of mind is security – states have a responsibility to protect citizen data from adverse access and use. Ensuring that all reasonable precautions are taken to prevent adverse access and exploitation of data and that government-grade and certified solutions are leveraged is key. This includes such features as being secure by default, access control profiles, advanced encryption, and redaction/anonymization. Beyond security, states should be considering enterprise-readiness such as complete disaster recovery and high availability options, cloud-neutrality, and multiple storage options.

RW: What are some of the common applications where states are realizing some of these benefits?

MS: We’re seeing a lot of success and interest in MMIS projects that leverage both our data integration and Master Data Management capabilities. For instance, as a part of the Systems Integration contract in a southwestern state, MarkLogic was selected as a system migration repository. This state saw migrating data from one system into another not just as a core challenge for its modernization effort, but rather as a key capability that would be frequently needed to facilitate data integration while adhering to MITA principles.
As another example, a southeastern state selected MarkLogic to be the data hub of their Enterprise Data Services (EDS) and serves as the Raw Data Lake and Operational Data Store for mastered citizen data, Medicaid members, Providers and other important entities. MarkLogic reduces manual data integration by providing 360° views that allow for faster and more accurate eligibility determinations, more complete and accurate enrollment and eligibility reporting and a lower TCO by reducing duplication of data across silos.

RW: – Scalability has been a common fail point for large scale integration projects, what is MarkLogic doing differently to meet with these challenges?

MS: MarkLogic was built for scale and it does so linearly on commodity hardware and in cloud environments. Yet while we most certainly benefit from great engineering innovation in our product, what sets MarkLogic apart on these projects is also our approach to actual integration. A great scalability example of this is the work we did for HealthCare.gov. Following the approval of the Affordable Care Act, the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) needed to design, build, and implement a technology platform capable of enrolling millions of Americans in new healthcare plans. CMS attempted to achieve this with a relational database, but the project failed, so CMS selected MarkLogic to meet its 18-month deadline. Today, CMS runs on MarkLogic as the largest personal data integration project in the government’s history.

RW: Looking to the future, how do you see the integration platform supporting state HHS transformation efforts in 5 years from now?

MS: Many states have now begun their IT modernization efforts, and this trend will continue to increase and the benefits will be more fully realized both in terms of meeting citizen needs and cost savings. I also believe that we will see a transition from traditional approaches for data design towards ones that favor greater innovation, agility, and simplified architectures.

Mark Logic is the 2019 TRACK 3 Sponsor
Enterprise Systems Planning, Health & Human Services Integration | Attend Mark Logics’s industry session Enterprise Data Hub as the New Medicaid Data Integration Pattern
Tuesday, March 19th • 2:45pm – 3:45pm


View 2019 State Healthcare IT Connect Final Agenda

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Brian Erdahl, Deloitte Consulting Principal and leader of Deloitte’s Medicare & Medicaid Enterprise Systems, sat down with Healthcare IT Connect’s Rob Waters to discuss Medicaid modernization and modularity.

Rob Waters (RW):Brian, we understand that Deloitte is leading four state Medicaid Enterprise System (MES) projects from a Systems Integration perspective. Can you give us a quick snapshot of the progress towards modularity?

Brian Erdahl (BE):Yes, there are great strides being made within all these projects. Each project is unique, but there are many similarities. The timeline and strategy for each state varies, but the overall goals are relatively similar—increasing flexibility, promoting efficiency through standardization, and providing better access to data that providers, members, workers, and others need to improve outcomes. At this point in time, all states have established solid work plans, governance, and communications. Technical platforms and initial security structures are in place with module integration discussions underway. States are considering common questions, too—topics like conversion, portals, and testing are top of mind.

RW:What do you see as the biggest benefits of the modular MES? Why do you think states should embrace modularization and modernization?

BE:We believe that the move to modularity will help organizations improve integration across the broader health care ecosystem—connecting stakeholders both within state agencies and with external entities providing health-related services. To improve health outcomes and manage costs, stakeholders increasingly need real-time data that they cannot access today. For example, consider a Medicaid member residing in a remote rural area that has limited access to health care services. In the future that member may access electronic medical records, receive virtual health care and monitoring, and continue to live independently. Legacy solutions typically have focused on administration, while the new MES increases focus on sharing information to improve health outcomes…among other benefits.

RW:So, let’s talk about outcomes. That word gets thrown around a lot. What does it mean in the context of MMIS modernization?

BE:That’s a great question. Outcomes is one of those words that means different things to different people. From our perspective, we have worked to build the foundation to support outcomes tracking and analytics. We have established a robust data architecture to efficiently capture the standardized information necessary to measure results across the spectrum—from individual health outcomes to overall population health, from individual provider performance to that of accountable care organizations, and from financial to operational performance.

RW:If you were to change one thing about the modularity movement, what would that be?

BE:This is something we have considered a lot over the last few years, and it comes down to one key concept: more emphasis on data access. When people hear “data access” they typically think tools. What is often an afterthought is planning and implementing a data architecture that supports that improved data access. We hear consistently that data quality, data silos, and vendor-locked data is a barrier to getting high-quality, consistent information. We take this very seriously in our role to bring solutions to our clients—helping to strategize and implement the future data architecture with the move to modularity.

Deloitte is the 2019 TRACK 1 Sponsor
Medicaid Modernization, Modularity and MES Procurement | Attend Deloitte’s industry session TRACK 1| Addressing Security in a Modular Environment
Tuesday, March 19th • 2:45pm – 3:45pm

View 2019 State Healthcare IT Connect Final Agenda

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Editor’s Note: John Selig is senior vice president at the Lewin Group, a national health and human services consulting firm owned by Optum.  He was previously the director of the Arkansas Department of Human Services, where he led several public health, human services, and technology initiatives.  A former Peace Corps volunteer, he is a frequent presenter at national forums on topics that include Medicaid, Social Determinants of Health, behavioral health, and payment reform.

John Selig, Senior Vice President, Lewin Group, sat down with Healthcare IT Connect’s Rob Waters to discuss the potential impacts of SDoH (Social Determinants of Health) data and how Medicaid is well positioned as a nationwide platform to utilize this data to better coordinate health, social programs, and community resources to improve outcomes.

Join John Selig on: Thursday, April 5  | 2:45pm – 3:45 p.m.  Track 2: Measuring and Managing the Social Determinants of Health

Rob Waters. First, can you explain what is meant by Social Determinants of Health (SDOH) and why they’re important to overall health outcomes?

John Selig:  Mounting evidence shows that socioeconomic factors – education level, access to nutritious food, physical safety, living environment, employment, and housing stability – affect well-being and may have a greater impact on a person’s overall health than health care services themselves.  Collectively, these factors are referred to as Social Determinants of Health and they are fast becoming an area of focus, especially when it comes to how once traditional “health care” dollars are spent.  The point is that health care alone can only go so far to improve health; how and where people live may be more important in determining overall health and longevity – your zip code may be more important to your overall health than access to traditional health care services.

RW. What evidence can you cite for this school of thought?

John Selig:  In their book, The American Healthcare Paradox: Why Spending More is Getting us Less, Yale researchers Elizabeth H. Bradley and Lauren Taylor posit the argument – based on comparative health data from 30 countries – that investing in social services directly correlates with a country’s overall health.  They point out that despite leading the world in per capita spending on traditional health care, the United States ranks near the bottom in many health outcomes; one reason why may be that the U.S. spends comparatively little on social services.  Moreover, they subsequently found the same holds true with U.S. states – those states with higher “social-to-health care” spending ratios generally have better health outcomes.

RW. Are there examples from states in which SDOH are part of the overall emphasis on better health?

John Selig: There are many, but I’ll cite two: one rural and one urban example.  In rural Kentucky, a diabetes coalition consults with area food banks and pantries to help them create “diabetes-friendly” food sections, and trains volunteers on healthier choices for people with diabetes – for example, green beans are preferable to corn.  And my “big city” example: New York’s Medicaid program invested in supportive housing for more than 11,000 of its highest cost and highest need beneficiaries – many of whom are homeless.  An evaluation by the State University of New York Research Foundation found that in the 12 months after these recipients were housed, the Medicaid program saw a 40 percent reduction in their in-patient hospital stays and a 26 percent reduction in their emergency department visits.

RW. How does this kind of investment in SDOH affect overall costs to a state?

John Selig: It may reduce costs in the long run, or allow public funds to be re-directed to other priorities.     And just think of the social supports you can afford when you cut unnecessary health costs. Depending on geographic region, one emergency department visit can be equivalent to a single month’s rent; two hospitalizations could equal one year of child care; and 20 MRIs could pay the salary of a social worker for a year – all “social” expenditures that can improve overall health.

RW. Does Medicaid play a key role in focusing on SDOH for better outcomes?

John Selig:  Definitely. The entire health system has a role in connecting with social programs, but Medicaid is well positioned to serve as a primary integrator.  Because Medicaid operates in all 50 states, it offers a common foundation on which to build these connections.  Also, as a federal and state partnership, Medicaid can be tailored to local populations while serving as the link to related social programs – and, targeted use of Medicaid funds on other social programs could eventually reduce overall Medicaid costs. Finally, Medicaid professionals have experience serving lower-income, resource-poor and often chronically ill populations with complex needs – individuals and families who would likely benefit most from a greater emphasis on social determinants to improve health.

RW. What kind of role does technology play in being able to link social programs with improved health outcomes?

John Selig: At the heart of developing an effective “culture of health” across health and other social programs is a state’s willingness to invest in technology that enables experts to see the links between those programs – and allows beneficiaries to more easily access the right supports at the right time. It’s important to identify the most pressing needs, get effective services to those who need them, and analyze and track results to know what’s working. For example, web-based, consumer-facing integrated eligibility systems allow individuals and families to simultaneously apply for Medicaid and other public health benefits, along with programs that administer food and cash assistance, child care assistance, and other supportive services. Strong data systems and analytics also provide states with capabilities to measure improvements and success.

RW. Any final thought on the benefits of focusing on SDOH to improve health?

John Selig:  Health care and social services systems need each other – to serve their communities as fully as possible, to contain costs, and to improve health outcomes.  We have a nationwide health care platform – Medicaid – on which states could build collaboration between agencies that provide traditional “health” services and those that offer other social services.  And we have the technology and analytical capabilities to link, monitor, and assess programs and outcomes.

Focusing on Social Determinants of Health is still a relatively new field, and work still needs to be done to explore which “social investments” will deliver the highest returns.  But it’s clear that investing in programs beyond traditional health care holds great promise to improve near and long-term health outcomes across the board and across the country.

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Brian Erdahl, Deloitte Consulting Principal and State Health Solution Architect, sat down with Healthcare IT Connect’s Rob Waters to discuss how evolving technologies support state programs and promote a connected healthcare ecosystem.

Rob Waters: With organizations focusing on pay-for-performance and health care outcomes, what techniques and technologies can be used to enable these changes?

Brian Erdahl: As organizations continue the migration towards a value-based care world, information architecture takes on a critical role to support the need for enhanced financial and healthcare quality analytics.  In the legacy world, this data typically has been locked in process-oriented systems.  With modularity, data may reside in disparate modules requiring data warehouse technologies to pull the dispersed information together for users.  Beyond this, the information architecture needs the capability to deliver real-time analytics to support workers in their day-to-day work and decision-making.  In addition, the information architecture should define and implement standards, tools, and enforceable service-level agreements (SLAs) to confirm data quality.

RW: In what ways do you envision the emerging “modular health ecosystem” helping states to enable a more connected multi-stakeholder environment?

BE: First, a modular approach allows states to capitalize on existing standards (e.g., X12, HL7, NIST, etc.) within their own ecosystems to move towards the standardized, interoperable environment envisioned by the Medicaid Information Technology Architecture (MITA).  This state modularization and associated standardization unlocks a world of connections with the broader health ecosystem.  The technologies deployed within states open up the ability to connect to a wide variety of information sources, including devices that monitor health readings, health information exchanges, longitudinal member health histories, and more.  Using the current technologies in a secure and open manner has the potential to share information like never before.  In turn, this can provide healthcare providers with appropriate access to information to help make critical healthcare decisions. 

RW: As states look to integrate the modular health ecosystem, how do you see the role of traditional systems integrators (SIs) evolving?

BE: Initially, we are seeing the systems integrator’s role being twofold – first being responsible for implementing an integration platform and an associated set of technologies and then working with other module vendors to implement information sharing through real-time services or traditional batch processes.  Over time, this role evolves to supporting and streamlining state health programs along the lines of MITA’s three architectures – business process, information, and technology.  In this role, the systems integrator helps streamline business processes and implements shared services to support cross-module functions. 

RW: With the shift to cloud-based Platform-as-a-Service (PaaS) implementations, what are the implications for a state procuring these services? 

BE: Systems integrators are providing the platforms to integrate disparate modules.  A PaaS model is well-suited for providing the standardized services required to integrate and share information since, by its nature, a PaaS model is based upon standards and reuse.  Likewise, PaaS supports integration across on-premise modules or other cloud-based modules in a secure and efficient manner.  A PaaS model can be an effective approach for states, but there are some important items to keep in mind during procurement.  For example, states should focus on SLAs and less on prescriptive tools, products, or architectures.  Another step is to define key compliance attributes like security standards, regulations, and standardized Application Program Interfaces (APIs).

Join Brian Erdahl on: Thursday, April 5 • 2:45pm – 3:45pm Track 1: Connecting People to an Informed Health Ecosystem | 2018 State Healthcare IT Connect Summit

 

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Tracy Waring Evans, Executive Director, APHSA sat down with HITC’s Rob Waters to discuss some of the opportunities and challenges H&HS agencies are facing in designing service delivery frameworks that maximize the opportunity provided by integrated data (including SDoH) and leverage community-based organizations.

Rob Waters: For this year’s plenary panel, APHSA has brought together a cross-section of state, local and provider level presenters. What did you learn during your conversations with panelists regarding “Designing for Impact in Integrated Service Delivery”?

Tracy Waring Evans: Health and human services systems, on the state, local and community levels, are embracing outcome-focused services informed by population-based data, whole family approaches, and advances in brain and behavioral sciences. The H/HS system is experiencing a shift from a reactive, crisis-oriented services delivery model to one that focuses “upstream” and better enables all of us to live to our full potential and to more effectively identify and address root causes when we do encounter roadblocks along the way. Integrated Service Delivery is a key aspect of this shift as it connects previously siloed programs, helps provide access to the right services at the right time, and enables learning environments that better inform us about what works to prevent the need for deeper-end services.

Technology is an important enabling factor in this effort. Many agencies are in the process of transitioning from legacy IT systems that “siloed” customer data to integrated systems that allow front-line workers to see a holistic picture of their clients and tailor services to best meet customer needs. The embrace of technology is occurring at all levels of H/HS, and that is why it is important to hear the perspectives from practitioners on the ground who are leading state and local efforts as well as those leading research efforts. Each brings a distinct perspective and helps paint a picture of the overall H/HS system of today, and what we hope to achieve in the future.

RW: There is a big focus at the moment on SDoH (Social Determinants of Health) and leveraging CBOs (Community Based Organizations) for population health/well-being outcomes, what are some of the challenges for agencies in further leveraging these resources?

TWE: We recently partnered with the Alliance for Strong Families and Communities, SeaChange Capital Partners, and Oliver Wyman on a report: A National Imperative: Joining Forces to Strengthen Human Services in America which focuses on the economic and social impact of human services community-based organizations (CBOs), and the need to strengthen and preserve their pivotal role in the larger human services ecosystem. One of the most important conclusions in the report is that CBOs play a critical role in augmenting state and local H/HS service delivery, but the overall financial health of the nation’s CBOs is not as strong as it should be and the risk of losing services delivered by CBOs is significant.

CBOs are at the forefront of service delivery just as front-line H/HS agency workers are. The direct contact they have with the clients they serve is invaluable in uncovering the SDoH factors that act as roadblocks to individuals, families and communities in reaching their full potential. One of the challenges related to the financial health of the CBO sector is that it is often under-resourced for critical IT upgrades or excluded from interoperability efforts. It is extremely important that all sectors of H/HS work together to ensure that CBOs are also able to maximize data to effectively deliver services and positively impact population health and well-being.

RW: What are some of the common challenges APHSA members are facing in purchasing and implementing IT services to support their integration objectives?

TWE: Many state and local agencies are bogged down by outmoded, legacy IT systems, and the budget pressure that they face is daunting. There are so many competing priorities – state and local governments are in a tough position when it comes to allocating funds, and are constantly looking for efficiencies in both process and costs.

RW: Could you share some insight on some of the work APHSA is undertaking to support your member efforts in this area?

TWE: Our collaborative center, the National Collaborative for Integration of Health and Human Services, in concert with our members and private industry partners has produced a number of toolkits and guidances to help our members with their integration initiatives. Most recently, it published a Guide to Data Management, Privacy & Confidentiality, and Predictive Analytics which lays out the building blocks of a data sharing strategy. The National Collaborative is at the forefront of H/HS systems integration, and our members and partners have done an incredible job at highlighting successful integration efforts and helping states and localities implement innovative technologies.

Join Tracey on: Thursday, April 5 • 10:45am – 11:45am Track 3: PLENARY – Designing for Impact in Integrated Service Delivery 2018 Healthcare IT Connect Summit

 

 

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Deb Grier, VP Enterprise Product Management, HMS sat down with Healthcare IT Connect’s Rob Waters to discuss innovations in Third Party Liability (TPL) solutions and how the evolution towards real-time eligibility determination is enabling states to move towards ‘cost avoidance’ based strategies and away from ‘pay and chase’.

Rob Waters: Third Party Liability represents one of the largest cost-savings opportunities for states to control costs and manage budgets, what should states be thinking about when they are examining the opportunity to evolve TPL to ‘Cost Avoidance’ and away from ‘Pay & Chase’?

DG: Emphasizing robust cost avoidance strategies will deliver improved financial results for states.  Back end recovery efforts are impeded as insurers impose more network and prior authorization requirements, which can be successfully managed on the front end. States need to be ready to adopt these strategies and embed them in their eligibility, financial, and claims management processes. Additionally, states must educate their partners and stakeholders on how these changes will affect them, and why they are important.  HMS can offer support to states in developing financial models that will demonstrate the value of cost avoidance and support funding requests and approaches.

While implementing front end cost avoidance strategies is essential, post-payment processes will still be necessary. Medicaid members’ circumstances change often; and the data discontinuities that occur between reporting changes, eligibility decisions, and claims submission can result in  primary payment by Medicaid when another party may be liable.

Additionally, federal guidelines still require states to pay up front for certain services and recover on the back end; and states are at varying readiness levels to adopt specific cost-avoidance strategies. For all these reasons, when looking to bolster cost savings opportunities, we recommend that states consider all transactional points along the healthcare continuum, from enrollment to post claims submission, that will be best served by the insertion of third party insurance identification and verification before a claim is paid by Medicaid. 

RW: What are some of the innovations in TPL that are enabling states to move to ‘real time’ coordination of benefits as part for the eligibility determination process?

A Medicaid member’s access to third party insurance is dynamic, which creates the need to inject TPL faster, more frequently and at more instances than have been historically considered.  While capturing a continually updated TPL status for all Medicaid members remains vital, HMS is focusing on innovations that bring forth TPL at the point of enrollment, point of prior authorization reviews and point of provider service and billing.  TPL data, while available at those junctures today, is often accessed manually.   HMS’s Enhanced Cost Avoidance suite of services removes the labor-intensive – and oftentimes overlooked – burden of this activity to support effective operations and ensure cost savings are maximized.

RW: How do these innovations align with the modular modernization of MMIS?

DG: HMS designed the technology platform that powers our enhanced cost avoidance suite of services with a decoupled strategy at its core. Our components are modular and flexible, providing services through well-defined API’s. This structure fosters reuse across multiple states and the opportunity for states to mix and match elements of our solution with their existing or planned systems. The platform aligns today with the MITA Modularity standard, with components that are built following a MicroServices approach that can be rolled-up to provide functionality for one or more business processes as defined in MITA business process model. In addition, the platform makes use of a business rules engine, thereby externalizing business rules from programming logic.

RW: What are the procurement options and funding mechanisms available for states to modernize their TPL systems (technology, services, re-use)?

DG:As the MMIS transforms to the Medicaid Enterprise System (MES), Medicaid agencies are faced with a decision on how to treat their TPL functions. With this shift in focus to system modularity, preserving cost containment functions is critical. A complete TPL solution is made up of a combination of data driven deliverables (such as cost avoidance and recoveries) and process driven services (such as subrogation recovery, premium assistance programs, and post payment recovery).  When preparing TPL procurements we recommend the following considerations:

• Understand your state’s TPL needs

• Consider your staffing constraints

• Ensure TPL staff have input on procurements

• Avoid forcing artificial partnerships

• Maintain continuity of recoveries and focus on the best results for all stakeholders

Our recommendation is to position TPL as a standalone procurement, either as its own module or as a service driven procurement, while creating greater interoperability with the core MES through the use of technology that facilitates information and data sharing. Regardless of the approach taken to procure and position TPL, our technology and services have been developed to integrate and exchange data seamlessly with other functions and modules.

Join Deb Grier on: Thursday, April 5 • 4:00pm – 5:00pm Track 4: Evolving Third Party Liability (TPL) towards ‘Cost Avoidance’ and beyond ‘Pay & Chase’, exploring state modernization and procurement models . | . 2018 Healthcare IT Connect Summit

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Eugene Sayan sat down with HITC’s Rob Waters to look towards the next phase of healthcare reform and to discuss some of the organizational and IT strategies states may want to consider to meet with the demands of a more modular and integrated H&HS ecosystem.

Rob Waters: Can you give a more in-depth description on the services you provide to payers and governments and how you differentiate yourself. How does Softheon deliver value to solve their challenges?

ES: Softheon provides an array of Medicaid reform technologies for both Medicaid Managed Care Organizations (MCO) and governments, including premium billing, eligibility verification, WRAP program management, delinquency & reconciliation, financial management, and data analytics. One of Softheon’s most valuable services is our agility. We differentiate ourselves from our competition by the fact that we have been able to adapt and thrive in a very unstable market. We are the industry pioneers working with early innovative states and plans. Some of our state partners include Indiana Healthy Insurance Plan (HIP 2.0), Arkansas Private Option (PO), New Hampshire Premium Assistance Program (PAP), New York Basic Plan (BP), and Kentucky Health.

RW: As states look towards the next phase of Medicaid transformation and marketplace reforms, potentially with more autonomy as to how they serve Medicaid populations. What do you see as the main opportunity for states to implement more ‘citizen focused’ services?

ES:  With the approval of Section 1115 Demonstration Waivers, states are getting more creative in serving their Medicaid populations. We’re seeing work requirements already approved in Kentucky and Indiana, and pending in AZ, UT, KS, AR, MS, WI, NH, and ME. Using 1115 Waivers along with 1332 ACA waivers has also come up in a few states recently, when making changes that impact both commercial and Medicaid lines of business.

In Idaho, there is an ongoing conversation about people that make too much to be on Medicaid but don’t hit the federal poverty level threshold to get tax credits. After proposing stopgap measures for years, this year they are trying to tie Medicaid and commercial changes together. This could impact more than 20,000 Idahoans, providing Medicaid eligibility through establishing a small eligibility group via the 1115 waiver.

Politics aside, the purpose of these waiver requests is for citizens to share a personal responsibility when using Medicaid funds, reducing waste while adding accountability for these people to proactively receive care.

Medicaid programs across the country are observing very interesting numbers: South Carolina recently saw a 29 percent drop in opioid prescriptions. According to the Lewin Report released last March, the majority (>50 percent) of HIP 2.0 Plus members could ‘always’ or ‘usually’ get routine appointments, get their prescriptions filled, and felt that the premiums were justified and were willing to pay a small monthly premium of $5 or more.

Reducing waste and increasing care are always the main opportunities with reforms, and the idea is to have ‘skin in the game’ so that the Medicaid population gets preventative care which leads to healthier population which leads to fewer claims, and so on.

RW: With a burgeoning ecosystem of ‘modular’ products and services now available for state Medicaid modernization, how does this align with Softheon’s approach and how you engage with your state customers?

ES:  Softheon’s cloud-based platform is comprised of modular components, architected to support modular implementations and mitigate the risk and uncertainty associated with ‘rip and replace’ challenges. This helps to set us apart, as other vendors attempt to extract code and bring new problems to otherwise functioning technologies. Health plans, MCOs, and states can avoid these risky extractions and the burdensome re-deployments. We offer these solutions as part of the Softheon Medicaid Administrative Cloud (MAC), which provides end-to-end functionality.

Since each state has its own unique approach to Medicaid, it can often be difficult assessing each individual need through our own gap analysis. Once we contact the state’s representatives, we show our main value proposition: MAC. With MAC, we reduce the need for IT infrastructure, dedicated personnel, and costly maintenance fees. Our value proposition is clear; the Cloud is the cheaper, faster, more secure option.

RW: The shift towards ‘modularity’ and away from ‘rip and replace’ has also put a lens on the re-use and integration of legacy IT investments. What advise do you have states when considering their data integration strategy?

ES:  I don’t necessarily think that ‘modularity’ and ‘rip and replace’ are antithetical to each other. We have seen many times, both in ACA and Medicaid, that carriers are willing to abandon their legacy IT strategies- provided the solutions are more affordable and easier to use. There are not many systems that can cover all the needs of a state or MCO. You have some systems that only cover billing under 1115 waivers, or some that only do eligibility verification. That is where the issues arise; these systems don’t or can’t communicate with each other or are inefficient. You would also need costly upgrades or licensing fees.

Of the 33 states that have expanded Medicaid, the amount of money that can be saved by having an integrated data strategy is immense. We already have seven states that have expanded programs using 1115 Waivers, and more are pending. The need for communication between states, providers, and members is paramount.

My advice to states that are considering data integration strategies are to look for a platform that can accommodate all of your needs: connect to the core system and speak the same language; have one modular platform that can do billing, enrollment, eligibility, analytics, and more; mitigate the risk and complexity away from built-in infrastructure to a cloud service; and finally, look for a service that is regularly upgraded and updated at no cost to you.

RW: How do you envisage these trends impacting future state procurements and the evolution of state IT workforces?

ES: Future state requirements will be a platform that is lean, secure, fast, stable, and modular. States will seek out systems like Softheon’s MAC to fulfill these requirements. We’ll see the move soon from Medicaid Management Information Systems (MMIS) throughout state and federal programs to more modular platforms. We need to get these disparate governmental systems to talk to one another; carriers, MCOs, providers, and members should have a platform that is easy and light that can securely communicate vital EHR and EMR to one another. We’re already seeing the move for Medicaid onto Amazon Web Services cloud to run analytics on 74 million lives. Wyoming has been using Google Apps for Government, NEOGOV for human resources, and other cloud-based platforms.

Medical loss ratios (claims paid out as a percentage of premiums) has improved, averaging 81% through the third quarter. This shows that markets have begun to stabilize, and health plans are returning to profitability.

I believe that the workforce population will remain the same, if not grow, but the specializations will change. The cloud is the natural progression of technology; there is less cost overall with faster implementation, and it can be accessed via secure website portal login. You will see less people being tasked with maintaining servers and infrastructure, thus freeing up personnel and capital to better manage their members.

This paradigm shift will enable states to focus more on quality of care and increase the ability to fight fraud, waste, and abuse. The cost savings will lead to lower premiums for the member population and greater overall satisfaction.

Join Eugene Sayan on: Thursday, April 5 • 2:45pm – 3:45pm Track 5: State Innovation Design and Implementation: Addressing ACA Marketplace Sustainability, Reform, and Positioning . | 2018 State Healthcare IT Connect Summit

 

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