Interview: The Next Phase of Healthcare Reform

Date: March 26, 2018||   0  Comments

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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