Interview w/ Melissa Boudreault, VP within State Health Solutions for CGI
Melissa Boudreault is Vice President within State Health Solutions for CGI, a leading IT and business process services provider. In this role, she works with states and commercial carriers across the country to develop blueprints and strategies for ACA and health care reform implementation.
A national leader in the strategy, design, and implementation of health insurance exchanges and the ACA, Ms. Boudreault was one of the founding Directors of the Massachusetts Health Connector.
Healthcare IT Connect sat down to discuss the current disposition of state health insurance exchanges (HIX) as health IT leaders implement State, State/Federal Partnership, and Federally-Facilitated Exchanges.
Zach Urbina: What role do Health Insurance Exchanges (HIX) play in Medicaid Expansion and State Health Reform?
Melissa Boudreault: That’s a very interesting question because health insurance exchanges represent a range of opportunities, including many that health and human services agencies would have liked to achieve for a number of years.
States going with state-based exchanges will be creating a new way of communicating with residents. They are designed to be accessible so will leverage technology that might seem commonplace – like ecommerce – but is not necessarily commonplace in healthcare.
These exchanges will have sort of a dual role. They need to help connect people with affordable insurance, but they also need to educate people. There are numerous opportunities for other agencies, particularly for Medicaid, to take advantage of these new platforms and try different things on the HIX side that could be brought over to Medicaid.
As marvelous as exchanges are, in order for them to be successful, they really have to find a way to coexist in the larger health and human services ecosystem. For example, it’s very hard to realize the full value of an exchange if you can’t integrate it with your eligibility systems.
One of the policy imperatives behind exchanges is to try to maintain a continuity of coverage and a continuity of care. So, if people have life changes or income changes and they move between different programs, the true vision we are all trying to achieve is to allow them to move seamlessly back and forth between the exchange and Medicaid.
That’s quite a challenge, particularly since so many state eligibility systems are legacy systems, and most of the exchange implementations are working on commercial off the shelf (COTS) platforms.
ZU: What opportunities should states be focused on when implementing their HIX to modernize their entire HIT infrastructure?
MB: This has been a very interesting area for companies like CGI that are working to help states realize their visions. Having spent a number of years on the Medicaid side of the house, one of the things that really has struck me is that we did system implementations in a very defined way, which basically was a technology transfer. You took the best from another state and then you spent a few years customizing it to your program. As we move to this COTS model, there are changes in terms of technology, but there also are changes in terms of governance, change management and business processes. We’re realizing that it is not as much about the technology, and how agencies can take advantage of it, but it is about all of the governance and business processes that need to be in place for the new system to be successful.
Any IT project typically requires a lot of effort, and timelines are aggressive for exchanges. As states look at the opportunities, they need to focus on flexibility for the future. The days of program changes taking six to nine months to roll out are gone. We will have more information available to us, and programs need to be more nimble to adapt to that knowledge. For example, if you come to learn there’s a very high percentage of heart disease in a particular area of your state, how can you modify your systems to be more responsive to that population? The expectation is that things will happen much more quickly than in the past.
As I mentioned earlier, the other big challenge is that an exchange is not an island. It cannot stand on its own. So, in the best case scenario, other technology projects would be in place or going live at the same time as an exchange. These include technology projects that have challenged us for years, such as the common member index and single sign-on for security.
If you could have a common member index to help manage the activity between individuals and households, and movement between programs, you would be in a place to really provide continuity of coverage. Without it, you face numerous challenges and manual work. If you could have single sign-on, you could make it possible for an individual to log into a state portal and access the full range of benefits available to them. If you do not have these things, you have to decide how to balance customer needs with what you have time to achieve.
These tend to be very desirable but very complex projects. What we’ve been advising states to do is to try to step back and take a critical look at what is possible to achieve. I think we’re going to see a number of states bring up their exchanges in October and January, and then try to tackle some of these other projects over the next calendar year.
ZU: What are some of the implications of implementing a HIX under the State-Federal Partnership and Federally Facilitated Exchange (FFE) model as opposed to the State-based model?
MB: Setting aside the political decisions that drove a lot of the decision making, one of the really exciting things about the way the Affordable Care Act (ACA) has been rolling out is the wide range of implementation opportunities available for states. I think the Centers for Medicare & Medicaid Services (CMS) has been very flexible about giving states the opportunity to evaluate what is going to be best for them.
For states choosing to hold back on a state-based exchange for now, they will have the benefit of seeing what early adopters will implement and know what is working, and will have the opportunity to leverage more things that will be in place at that time. Although most state-based exchange initiatives are implementing COTS-based solutions, there certainly are different approaches.
In every single state implementing a state-based exchange, there is a tremendous amount of energy and momentum around that exchange. This won’t be the case with FFE and state-federal partnership models. Part of this has to do with resources, but a lot has to do with the fact that you have a very clearly defined end goal. Having a lot of energy, enthusiasm and focus makes many things possible. I think states choosing not to pursue a state-based exchange will lose an opportunity to try to achieve wide-scale IT improvements or business process changes because it is much harder to generate the momentum if you’re doing more discrete projects, such as just plan management or outreach. These states will be leaving a large driver of their program in hands outside the state.
ZU: And what are some of the IT complexities of the 3 different models?
MB: With state-based exchanges, the challenges we have come across are being solved together by the vendor communities and the states. Nobody has direct experience in this because it is new. I came out of an innovator state as a founder of the Massachusetts Connector. Even there, we used existing systems, so that program did not go through all of the phases of this type of implementation.
The big IT challenge for the state-based model is that we’re working with very flexible and nimble COTS solutions that take advantage of the best technologies available, but those COTS solutions need to talk to other state systems. Figuring out how to build the interfaces, especially to legacy systems, without causing upheaval in other areas, is difficult. So, trying to bring in a COTS solution that can’t stand on its own is a key challenge.
Another challenge around IT for state-based exchanges is that it’s tough to spell out the requirements. Historically, with Medicaid Management Information System eligibility implementations for example, there’s always been a group of subject matter experts within an agency who know the programs intrinsically and who can really articulate what they need. With HIX, however, we do have some guidance from boards and other entities, but developing requirements and getting business users comfortable with what you are going to implement is definitely a challenge.
For state-federal partnerships and the FFE, if you are not getting the resources to build new systems, that is a lost opportunity. Additionally, you will still need to make some changes. Without having that energy, focus and momentum that we talked about earlier, that is going to be more difficult.
I’m a really big believer that we can fix a lot of problems with IT, but it tends to be on the business side that the hard work has to take place. With state-federal partnerships and the FFE, the work will change for states. There will be phone calls from new people coming into the system and files coming from the federal government. So, one of the biggest IT challenges is around preparing your business users for the degree of change coming and the fact that programs are evolving. Especially for those states choosing the FFE route, that evolution is going to be driven outside of the traditional agency environment.
Part II of Healthcare IT Connect’s interview with Melissa Boudreault of CGI will be published two weeks from today, and include four additional in-depth questions and answers on the HIX implementation landscape.