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COVID-
19 and opportunities to reboot managed care

09.16.20

Read this if you are a state Medicaid agency, state managed care office, or managed care organization (MCO). 

The COVID-19 pandemic and resulting economic downturn has led to increased Medicaid member enrollment and has placed a strain on state budgets to support Medicaid and other health and human services programs. It has also impacted traditional Medicaid utilization patterns and has challenged provider reimbursement models, forcing managed care programs and supporting MCOs to:

  • rethink the control of program costs, 
  • seek MCO program flexibilities to expand coverage such as telehealth, and 
  • make operational changes to support their growing member populations.

Managed care opportunities

While COVID-19 has created many challenges, at the same time it has given managed care programs the opportunity to restructure their delivery of services not only during the public health emergency, but for the longer term. Flexibilities sought this year from the Centers of Medicare & Medicaid Services (CMS) put in place through waivers and state plan amendments have helped expand services in areas such as the delivery of COVID-19 testing, medical supplies, and behavioral health services via telehealth. 

These flexibilities have relieved the administrative burden on Medicaid programs, such as performance and reporting requirements outlined under federal law and 42 CFR §438. Although these flexibilities have helped managed care programs expand services during the pandemic, the benefits are temporary and will require MCOs to make programmatic changes to meet the demands of its population during and after the public health emergency.

A recent study by Families USA cited 38 states reporting 7% growth in member enrollment since February. As the Medicaid population continues to grow in 2020 and beyond, managed care programs have numerous opportunities to consider: 

Managing care coordination and establishing efficiencies with home- and community-based services (HCBS)

The increased risk of adverse health outcomes from COVID-19 due to older age and chronic illness, and the demands on providers and medical supplies, has forced Medicaid programs to seek waiver flexibilities to expand HCBS. As part of HCBS delivery, MCOs may focus on the sickest and most costly of their member populations to control costs and preserve quality. 

MCOs will most likely monitor cost drivers such as chronic conditions, catastrophic health events, and frequent visits to primary care providers and hospitals. MCOs have the opportunity to establish efficiencies and improve transitions across different providers and multiple conditions to better manage the over-utilization of services for members in skilled nursing facilities, and for those who receive HCBS and outpatient services.

Adjusting and monitoring Value-Based Payment (VBP) models

With the continued transition to VBP models, Medicaid programs face the challenge of added costs and adapting plan operations and services to address pandemic-related needs, chronic conditions, and comorbidities. 

Building on the latest guidance to state Medicaid directors from CMS on value-based care, Medicaid programs can look at COVID-19 impacts on provider reimbursement prior to the rollout of VBP models. Medicaid programs can continue establishing payment models that improve health outcomes, quality, and member experience. States can adjust contracts and adherence to local and state public health priorities and national quality measures to advance their VBP strategy. Managed care programs may need to consider a phased rollout of their VBP models to build buy-in from providers transitioning from traditional fee-for-services payment models, and to allow for refinements to current VBP models.

Continued stratification and the assessment of risk

By analyzing COVID-19’s impact on the quality of care and member experience, improved outcomes, and member and program costs, managed care programs can improve their population stratification methodologies factoring as population demographic analysis, social determinants of health, and health status. Adjustments to risk stratification during and after the COVID-19 pandemic will inform the development of provider networks, provider payment models, and services. Taking into account new patterns of utilization across its member population, managed care programs may need to refine their risk adjustment models to determine the sickest and most costly of their populations to project costs and improve the delivery of services and coordination of care for Medicaid members.

Telehealth

As providers transition back to their traditional structures, MCOs can continue to expand telehealth to improve service delivery and to control costs. Part of this expansion will require MCOs to balance the mentioned benefits of the telehealth model with the risk of over-utilization of telehealth services that can lead to inefficiencies and increased managed care program costs. In addition, because of the loosening of federal restrictions on telehealth, managed care programs will most likely want to update program integrity safeguards to reduce the risk of fraud, waste, and abuse in areas such as provider credentialing, personal identifiable information (PII), privacy and security protocols, member consent, patient examinations, and remote prescriptions. 

Continued focus on data improvement and encounter data quality

Encounter data quality and data improvement initiatives will be critical to successfully administer a managed care program. As encounter data drives capitation rates for MCOs, a continued focus on encounter data quality will likely enable Medicaid programs to better leverage actuarial services to establish sound and adequate managed care program rates, better aligning financial incentives and payments to their MCOs. 

States have pursued a number of flexibilities to establish a short-term framework to support their managed care programs during the COVID-19 pandemic. However, the current expansion of services and the need for MCOs to rapidly identify additional areas for operational improvements during the pandemic have allowed Medicaid programs to further analyze longer-term needs of the populations they serve. These developments have also helped programs increase their range of services, to expand and manage their provider networks, and to mature their provider payment models. 

If you would like more information or have questions about opportunities for adjustments to your managed care program, please contact MedicaidConsulting@BerryDunn.com. We’re here to help.
 

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Read this if you are a state Medicaid agency, state managed care office, or managed care organization (MCO).

The November 9, 2020 announcement by the Centers for Medicare & Medicaid Services (CMS) outlines updates to the 2016 Medicaid & Children's Insurance Program (CHIP) Managed Care Final Rule (Final Rule), which present new challenges to state Medicaid and CHIP managed care programs to interpret the latest CMS guidance that attempts to relieve current administrative burdens and federal regulatory barriers.

Although the latest guidance by CMS attempts to provide potential relief to states to administer their managed care programs, states will need to coordinate with federal and state partners to further understand the latest updates to federal regulations that are presented by the updated Final Rule.

By providing relief for current reporting requirements for program costs, provider rates, network adequacy, and encounter data, this latest change by the administration enables state managed care programs to reassess current operations to update and improve their current service delivery. The updated Final Rule continues CMS’ efforts to transition state managed care and CHIP programs from a fee-for-service delivery system, and to urge state Medicaid and CHIP agencies to continue to implement payment models to improve quality, control costs, and promote innovation.  

Impacts on Medicaid managed care operations 

Changes for states to consider that impact their Medicaid managed care operations based on the latest Final Rule include:

  • Coordination of benefits agreements (COBA): States will have the option to leverage different methodologies for crossover claim distribution to managed care plans, and the updated Final Rule indicates that managed care plans do not have to enter into COBA directly with Medicare.
  • Rate setting and ranges, and development practices: CMS provides the option for states to develop and certify a rate range and has provided clarification and different options for rate setting and development practices.
  • Network adequacy: CMS will allow for states to set quantitative network standards, such as provider to enrollee ratios, to account for increases in telehealth providers and to provide flexibilities in rural areas.
  • Provider directory updates: CMS will allow for less than monthly updates to provider directories due to the increased utilization of digital media by enrollees, emphasizing decreased administrative burden and the costs for state managed care plans. This update also indicates that completion of cultural competency training by providers will no longer be required.
  • Provider termination notices: The latest update increases the length of provider termination notice requirements to 30 calendar days (previously 15 calendar days).
  • Member information requirements: The latest update outlines flexibilities for enrollee materials as it relates to font size and formatting.
  • Quality Rating System (QRS): CMS will be developing a QRS framework in which states must align with, but will be able to develop uniquely tailored approaches for their state.
  • External quality review: States that exempt managed care plans from external quality review activities must post this information on their websites for public access on an annual basis.
  • Grievance and appeal clarifications: The latest update provides clarification that the denial of non-clean claims does not require adverse benefit determination notices and procedures; adjustments and clarification to State Fair Hearing enrollee request timeframes to align with recent Medicaid fee-for-service requirements

CHIP to Medicaid regulatory cross-references

CMS clarifies several CHIP to Medicaid regulatory cross-references. These cross-references include the continuation of benefits during State Fair Hearings, changes to encounter data submission requirements, changes to Medicaid Care Advisory Council (MCAC) requirements, grievance and appeals requirements, and program integrity standards.

Changing demand on managed care programs

The November 9 announcement follows a series of efforts by CMS during the past few years to modify the Final Rule in an attempt to help states meet the changing demands on their managed care programs. For the 2016 Final Rule, CMS formed a working group with the National Association of Medicaid Directors (NAMD) and state Medicaid directors to review current managed care regulations. The recommendations from the group led to public comment in November 2018 with state Medicaid and CHIP agencies, advocacy groups, health care providers and associations, health insurers, managed care plans, health care associations, and the general public. As a result of this public comment effort, the latest Final Rule seeks to streamline current managed care regulations.

The new Final Rule announcement comes after a series of efforts by CMS to offer guidance and make changes to their provider payment models, including its recent September 15 letter to state Medicaid directors that further promotes a strategic shift towards value based payments to transform the alignment of quality and cost of care for Medicaid beneficiaries.

The effective date for the new regulations will be 30 days after publication of the new Final Rule in the Federal Register (target date November 13, 2020), except for additions §§ 438.4(c) and 438.6(d)(6) for Medicaid managed care rating setting periods, which are effective July 1, 2021.

If you would like more information or have questions about interpreting the Final Rule for changes to your managed care program, please contact us.

Article
The 2020 Final Rule—Understanding new flexibilities to control costs and deliver care

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

You can listen to the companion podcast to this article, Organization development: Shortcuts for states to consider, here: 

Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

What organization development (OD) shortcuts can state Medicaid agencies consider when faced with competing priorities and challenges such as Medicaid modernization projects in flight, staffing shortages, and a retiring workforce?

The shortcuts include rapid development and understanding of the “why”. This requires the courage to challenge assumptions, especially around transparency, to allow for a consistent understanding of the needs, data, environment, and staff members’ role in impacting the health of the people served by a state’s Medicaid program. To rapidly gain an understanding of the “why”, state Medicaid agencies should:

  1. Accelerate the transparency of information and use of data in ways that lead to a collective understanding of the “why”. Accelerating a collective understanding of the why requires improved communication mechanisms. 
  2. Invest time to connect with staff. The insistence, persistence, and consistency of leaders to stay connected to their workforce will help keep the focus on the “why” and build a shared sense of connection and purpose among teams.
  3. Create the standard that planning involves all stakeholders (e.g., policy, operations, systems staff, etc.) and focus on building consensus and alignment throughout the organization. During planning, identify answers to the following questions: What are we trying to achieve, what are the outcomes, and what is the vision for what we are trying to do?
  4. Question any fragmentation. For example, if there is a hiring freeze, several staff are retiring, and demand is increasing, it is a good idea to think about how the organization manages people. Question boundaries related to your staff and the business processes they perform (e.g., some staff can only complete a portion of a business process because of a job classification). Look at ways to broaden the expectations of staff, eliminate unnecessary handoffs, and expect development. Leaders and teams work together to build a culture that is vision-driven, data-informed, and values-based.

What are some considerations when organizations are defining program outcomes and the “why” behind what they are doing? 

Keep in mind that designing system requirements is not the same as designing program outcomes. System requirements need to be able to deliver the outcomes and the information the organization needs. With something like a Medicaid Enterprise System (MES) modernization project, outcomes are what follow because of a successful project or series of projects. For example, a state Medicaid agency looking to improve access to care might develop an outcome focused on enabling the timely and accurate screening and revalidation for Medicaid providers. 

Next, keeping with the improving access to care example, state Medicaid agencies should define and communicate the roles technology and staff play in helping achieve the desired outcome and continue communicating and helping staff understand the “why”. In Medicaid we impact people’s lives, and that makes it easy to find the heart. Helping staff connect their own motivation and find meaning in achieving an outcome is key to help ensure project success and realize desired outcomes. 

Program outcomes represents one of the six major categories related to organizational health: 

  1. Leadership
  2. Strategy
  3. Workforce
  4. Operations and process improvement 
  5. Person-centered service
  6. Program outcomes

Focusing on these six key areas during the analysis, planning, development, and integration will help organizations improve performance, increase their impact, and achieve program outcomes. Reach out to the BerryDunn’s Medicaid and Organization Development consulting team for more information about how organization develop can help your Medicaid agency.
 

Article
Outcomes and organization development, part II

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts. 

The companion podcast to this article, Organization development: Preparing for Medicaid Enterprise Systems (MES) modernization, can be found in our virtual library.  


What is organization development (OD)? 

The purpose of OD is to improve organizational performance and outcomes. OD focuses on improving an organization’s capability through the alignment of strategy, structure, people, rewards, systems, metrics, and management processes.  

OD is a science-backed, interdisciplinary field rooted in psychology, culture, innovation, social sciences, quality management, project management, adult learning, human resource management, change management, organization behavior, and research analysis and design, among others.  

OD typically starts with a clear sense of mission, vision, and values that answers the question “what we are trying to be?” OD develops the culture and behaviors that reflect the organizational values.  

OD facilitates the transformation of the workplace culture to become strategic, meaning: vision-driven, values-based, and goals-aligned. This may include talent development for leaders and staff and redesigning organizational infrastructure. 

What is the scope of an OD effort? 

OD efforts are most effective when they encompass the entire organization becoming the basis for a strategic plan. OD can be just as effective when applied to a MES modernization project. In this application of OD, we facilitate stakeholder engagement with the intent of person-centered service, concurrent design for operations, processes, and training side-by-side with the systems design and development. This approach is also referred to as human-centered design (HCD).  

Regardless of the scope, OD reinforces benchmarks of high-performance organizations including: 

  • Transparent and data-informed decision making 
  • Developed leadership building connections with consistent expectations 
  • Culture of continuous improvement and innovation 
  • Team-based success and ownership for outcomes 
  • Person-centered service 

What does OD look like in action? 

We facilitate leaders to assess their organization through the eyes of stakeholders, particularly staff and people served. Collaboratively, with no blame or shame, the leaders articulate where they are today and where they need to be in the future, and build a roadmap or strategic plan to get there. In the assessment and roadmap we use the following six focal points of the organization:  

  • Excellent leadership 
  • Effective strategy 
  • A workforce that is confident, competent, consistent, and compassionate 
  • Quality operations and process improvement 
  • Person-centered service that results in a positive client experience 
  • Quality program outcomes for the communities served 

The roadmap or strategic plan typically includes talent development, and redesign of the infrastructure, including structure, processes, communication mechanisms, performance management processes, deployment of resources, and job skills development approaches.  

Talent development ensures that your leaders are aligned, prepared, and most importantly leading and inspiring their people toward that vision and the development of the workforce. Talent development provides staff with the skills, knowledge, and abilities needed, and reinforces positive attitudes, beliefs, and willingness to work together towards common goals. This might also include restructuring business process redesign, it might include expanding roles or shifting roles.  

Principles of lean are an important component of organization development when redesigning processes and helps organizations, such as state Medicaid agencies, do more with the current resources. With so many constraints placed on organizations, the lean approach is a critical component of optimizing existing resources and finding cost savings through changing “what we do” and “how we do it”, as opposed to cutting “what we do” or “changing who does it”. Resource optimization is just one of the benefits of organization development. 

Why is it important to redesign your organization and develop your staff when you're implementing a new technology system, such as a new Medicaid Enterprise System module? 

For state Medicaid Agencies, the organization goal isn't to modernize a system, the goal is for competent and compassionate staff serving clients and providers to improve health and wellness in our communities. Our goal is streamlined processes that improve accuracy and timeliness. Look at the outcomes of the program, then design the systems that enable business processes and the people who make that process happen every single day. We go back to why we are doing anything in the first place. Why do we need this change? What are we trying to accomplish? If we're trying to accomplish better service, a healthier community, and streamline processes so we are cost effective, then it leads us to modernizing our enterprise system and making sure that our people are prepared to be successful in using that system. Aligning to the organizational goals, or what we call the North Star, sets us up for success with the enterprise efforts and the human efforts. 

What can clients do to navigate some of the uncertainties of a modernization effort, and how can they prepare their staff for what's next? 

First articulate the goals or why you want the modernization, and build a foundation with aligned, and effective leaders. Assess the needs of the organization from a “social” or people perspective and a technical or systems perspective (note: BerryDunn uses a socio-technical systems design approach). Then, engage staff to develop a high-performance, team-based culture to improve lean processes. Design and develop the system to enable lean business processes and concurrently have operations design standard operating procedures, and develop the training needed to optimize the new system.  

Leaders must lead. If leaders are fragmented, if they are not effective communicators, if they do not have a sense of trust and connection with their workforce, then any change will be sub-optimized and probably will be a frustrating experience for all.  

If the workforce is in a place where staff live with suspicion or a lack of trust, or maybe some dysfunctional interpersonal skills, then they are not in a place to learn a new system. If you try to build a system based on a fragmented organizational structure or inconsistent processes, you will not achieve the potential of the modernization efforts and will limit how people view your enterprise system. The worst thing you can do is invest millions of dollars in the system based on a flawed organizational design or trying to get that system to just do what we've always done. 

By starting with building the foundation of engaging employees, not just to make people feel good, but also to help them understand how to improve their processes and build a positive workplace. Do we have the transparency in our data so that we understand what the actual problems are? Can employees articulate the North Star goals, the constraints, the reasons to update systems, then the organizations will have a pull for change as opposed to a push.

Medicaid agencies and other organizations can create a pull for change by engaging with their resources who can identify what gets in the way of serving the clients, i.e., what gets in the way of timeliness or adds redundancy or rework to the process. The first step is building that foundation, getting people leaning in, and understanding what's happening. By laying the foundation first, organizations help reduce the barriers between operations and systems, and ensure that they're working collaboratively toward organizational goals, always keeping the ‘why’ in mind and using measures to know when they are successful. 

How does a state focus on organization development when they are facing budget and staffing constraints? 

It is too easy to say, "invest in your people". In reality, the first thing that state Medicaid agencies or other organizations need do is redefine their sense of lean. Many inaccurately believe that lean means limited resources working really hard. Lean is tapping into the potential creativity and innovation of each staff member to look for ways to improve the process. Organizations should look at everything they do and ask “Does this add value to the end recipient of our service?” Even if I'm processing travel reimbursement requests, I still have a customer, I still have a need for timeliness and accuracy. If state Medicaid agencies can mobilize that type of focus with every single employee in their organization, they can achieve huge cost savings without the pain of cutting the workforce.   

In one state where BerryDunn’s organization development team provided this level and type of organizational transformation, there was a very deliberate focus on building this foundation prior to a large-scale system modernization.

By developing the leaders and training the employees in how to improve their processes, improve teamwork and trust, and align to the goal of a positive client experience, they were able to effectively implement the new system and seamlessly move to remote pandemic conditions. Once the state Medicaid agency had aligned the technical systems and the people systems to the organizational goals, they were successful and more resilient for future changes.   

If you have any questions, please contact our Medicaid consulting team. We're here to help.

Article
Outcomes and organization development 

Read this if you work in an alcohol control capacity for state government.

The COVID-19 outbreak has changed the alcoholic beverage industry significantly over the last 14 months. Restrictions forced people to stay at home, limiting their travel to restaurants, bars, and even some stores to purchase their favorite spirits. In at least 32 states, new legislation allowed consumers the option to buy to-go cocktails as a way to help these establishments stay in business. As a result, consumers took advantage of alcohol delivery services. 

There were two large shifts in consumer purchasing for the alcoholic beverage industry in 2020. The first was a shift from on-premise to off-premise purchasing (for example, more takeaway beverages from bars, breweries, and other establishments). The second was the explosion of e-commerce sales for curbside pickup and home delivery. A study by IWSR, an alcoholic beverage market research firm, stated that alcohol e-commerce sales grew 42% in 2020. The head of consumer insights for the online alcoholic beverage delivery service, Drizly, attributes this growth to the “increased consumer awareness of alcohol delivery as a legal option, as well as an overall shift in consumer purchasing behavior toward online ordering and delivery”. 

How state agencies responded

The move to an e-commerce model has impacted state agencies who regulate the distribution and/or sale of alcohol. States such as Oklahoma, Alabama, and Georgia recently passed legislation allowing alcohol delivery to consumers’ homes. In alcoholic beverage control states, where the state controls the sale of alcohol at the wholesale level, curbside pickup programs (New Hampshire) were implemented, while others started online home delivery services (Pennsylvania). 

In a fluid legislative environment, states agencies are working to meet consumer needs in a very competitive marketplace, while fulfilling their regulatory obligation to the health and safety of their constituents.

How alcoholic beverage control states can adapt

Now is an opportune time for control state agencies to keep pace with consumer demand for more flexible purchasing options, such as buying online with home delivery, or some form of curbside and/or in-store pickup programs. Every one of the 17 alcoholic beverage control states has passed legislation to allow the delivery of either beer, wine, and/or distilled spirits in some form, with some limitations.

While for some the COVID-19 outbreak has necessitated these more distant shopping experiences, the option of these sales channels has brought consumers flexibility they will expect going forward. This calls for control state agencies to act on this changing consumer demand. By prioritizing investing in and taking ownership of new sales channels, such as e-commerce and curbside pickup, control state agencies’ technology and logistics teams can develop strategies and tools to effectively adapt to this new demand. 

Adapting technology and logistics

Through technology, control state agencies can take advantage of e-commerce and curbside pickup sales channels, to drive more revenue. We recommend control states consider the following: 

Define the current capabilities to support an online sales strategy

An important first step is to define how to address constituents’ evolving needs as compared to the current e-commerce capabilities control state agencies can support. Considerations include:

  • Are current staff capable of developing and supporting new website capabilities to meet the increased demand on the website?  
  • How will the current customer support team(s) expand to support concerns from the new channels?
  • How will new e-commerce order volume be fulfilled for home delivery (including order errors, breakage, returns, etc.)?   

Control state agencies should complete current and future state assessments in each area above to confirm what capabilities they have today and which they would like to have in the future; which will allow for an accurate gap analysis and comparison to their future state needs. Once the current state assessment, future state strategy, and gap analysis are complete, control state agencies can define the projects required to support the future state requirements. 

Reevaluate existing fulfillment, inventory, and distribution processes

Each control state has existing product fulfillment, inventory and distribution processes, and information technology (IT) tools for delivering alcohol, to their own or licensed retail stores and businesses. These current processes and IT systems should be assessed as part of the current state capabilities assessment mentioned above, to help define the level of change needed to support the control state agency’s future needs in the e-commerce channel. Key assessment questions control state agencies should ask themselves include: 

  • Can the current IT systems (e.g., inventory management, customer relationship management [CRM], customer support/call center, financial, point of sale [POS], and website infrastructure) support required upgrades?
  • Can retail teams and today’s infrastructure support order taking, inventory, fulfillment, and buy online pickup in store programs?
  • How will warehouse and retail stores track and manage the e-commerce shipments and returns related to this channel?
  • If home delivery is part of the strategy, define how the delivery logistics will be met through state or vendor resources.
  • What staffing model and skill sets will support future business needs?
  • What is the total cost of ownership for these new e-commerce capabilities so that the short and long-term costs and profits can be accurately estimated? 

The answers to these questions will help to inform a future e-commerce strategy and accommodate the cost and staff impacts. 

Bring in online retail expertise

It is important to ensure that the control state agency has website and mobile capabilities to support today’s consumer needs. This includes the ability to order a wide range of products online for either home delivery or buy online pickup in store. The design of the website and mobile transactional capabilities is critically important to the success of this channel, the true growth in revenues. Being marketing focused (e.g., allowing consumers to view and order products, save items for later, and see similar products) will help drive traffic and sales on this upgraded channel. 

For control state agencies with a more static product website, consider purchasing a commercial off-the-shelf (COTS) e-commerce product with existing retail-focused website features, or contract with a vendor to build a website that meets more unique needs. The control state agency should bring in at least one online retail subject matter expert vendor to help set the direction, design the upgrades or new site, manage the project(s) needed to implement the online capabilities, and potentially manage the operational support of the website and mobile solution.

BerryDunn provides state alcoholic beverage control boards and commissions with many services along the IT system acquisition lifecycle, including planning, needs assessment, business process analysis, request for proposal (RFP) development, requirements development, technology contract development, and project management services. 

For the full list of steps to consider and to learn more about how you can successfully position your control state agency to adapt to the changing alcoholic beverage landscape, contact us.
 

Article
COVID-19 and the e-commerce explosion

Read this if you are at a state Medicaid agency.

In early March 2021, the Biden administration passed the American Rescue Plan of 2021 (H.R.1319) with the primary goal of providing emergency supplemental funding for the ongoing response to the COVID-19 pandemic. Importantly, in addition to vaccines, unemployment, and other critical developments, the plan provided a number of Medicaid opportunities for states that expand eligibility and coverage, including the following:

  • Funding increases—a new incentive to expand Medicaid eligibility through a two-year, 5% increase in the state’s base Federal Medical Assistance Percentage (FMAP).
  • Coverage—the option to extend Medicaid coverage for women up to 12 months postpartum and with full Medicaid benefits.
  • System transformation—a one-year, time-limited FMAP increase of 7.35% for states to make improvements and rate increases to Medicaid home-and-community-based services (HCBS).
  • Waiver opportunities—a new incentive (enhanced FMAP for five years through bundled payments) for state Medicaid programs’ mobile crisis intervention services for individuals experiencing a mental health or substance use disorder crisis via a state plan amendment (SPA) or 1115 waiver demonstration.

What’s next?

It seems likely that the American Rescue Plan’s Medicaid provisions signal upcoming changes and opportunities for healthcare transformation for state Medicaid programs. The administration has consistently articulated a desire to “strengthen Medicaid” and while additional legislative actions are likely coming, there are also legislative limitations that may limit or curtail the type of broad reform we’ve seen in the past. As a result, it’s likely that the vehicle the administration will use to disseminate healthcare transformation in Medicaid are administrative actions such as executive orders, regulations, and administrative rule-making through the Centers for Medicaid and Medicare Services (CMS). This is likely to result in opportunities in two areas: waivers and the funding incentives to adopt new policies.

Waivers

The best tool the administration has is also one of its oldest: demonstration waivers. As noted above, the American Rescue Plan of 2021 includes the option for states to take advantage of waivers (as well as SPAs) to exercise new flexibilities. Unlike the Affordable Care Act (ACA) which was rolled out nationally, it’s likely the administration will seek out volunteer states that are innovative and willing to collaborate. The result will be more experimentation, more tailoring of policy, and a more gradual—even organic—approach to transformation.

In the short term for state Medicaid agencies this will mean a rebalancing of pending waivers and guidance. Prior policy priorities like work requirements and aggregate enrollment caps may be revised through the regulatory process in coming months or years. It is anticipated that CMS will execute a vision with a renewed focus on expanding services or coverage, much like those seen with the opportunities already presented under the American Rescue Plan.

Funding

Budget is a consistent challenge states have faced over the past year resulting largely from the COVID-19 pandemic. Even with recent aid to states and local governments there is likely to be uncertainty for the immediate future. The American Rescue Plan, like the ACA before it, finds mechanisms and incentives to raise the FMAP for states and potentially ease the state’s portion of Medicaid funding, particularly in the short term. Fitting with the theme of states as active partners, going forward there will likely be opportunities to maintain some type of increase to the FMAP. Beyond direct funding, opportunities like the recent CMS guidance on social determinants of heath, value-based payments, and models like the Community Health Access and Rural Transformation (CHART) hint at a continued focus on payment reform. States looking to lower costs and/or increase the quality of care will have ample opportunities to undertake projects in these areas.

State considerations

Regardless of next steps, states should expect both compliance needs and opportunities. States should begin to consider strategy, resources, and their priorities now. This process begins with knowing your agency’s strengths and potential limitations. Once states set their policy priorities and are ready to get underway with the business of transformation, time and resource constraints will likely be common barriers. Having a mature, flexible, and capable project management office, the right subject matter knowledge, and prequalified vendor lists to assist with Medicaid transformation can go a long way towards addressing time and resource constraints—making state Medicaid agencies agile in their response to the unique opportunities in the coming years.

Article
What's past is prologue: How the American Rescue Plan shows us what's next for Medicaid 

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

Click on the title to listen to the companion podcast to this article, Medicaid Enterprise Systems certification: Outcomes and APD considerations

Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

How does the focus on outcomes impact the way states think about funding for their Medicaid Enterprise Systems (MESs)?

Outcomes are becoming an integral part of states’ MES modernization efforts. We can see this on display in recent preliminary CMS guidance. CMS has advised states to begin incorporating outcome statements and metrics into APDs, Requests for Proposals (RFPs), and supporting vendor contracts. 

Outcomes and metrics allow states and federal partners to have more informed discussions about the business needs that states hope to achieve with their Medicaid IT systems. APDs will likely take on a renewed importance as states incorporate outcomes and metrics to demonstrate the benefits of their Medicaid IT systems.

What does this renewed importance mean for states as they prepare their APD submissions?

As we’ve seen with initial OBC pilots, enhanced operations funding depends upon the system’s ability to satisfy certification outcomes and Key Performance Indicators (KPIs). 

Notably, states should also prepare to incorporate outcomes into all APD submissions—including updates to previously approved active APDs that did not identify outcomes in the most recent submission. 
 
This will likely apply to all stages of a project’s lifecycle—from system planning and procurement through operations. Before seeking funding for new IT systems, states should be able to effectively explain how the project would lead to tangible benefits and outcomes for the Medicaid program.

How do outcome statements align with and complement what we are seeing with outcomes-based or streamlined modular certification efforts?

Outcomes are making their way into funding and contracting vehicles and this really captures the scaling we discussed in our last conversation. States need to start thinking about reprocurement and modernization projects in terms of business goals, organizational development, and business process improvement and redesign. What will a state get out of the new technology that they do not get today? States need to focus more on the business needs and less on the technical requirements.

Interestingly, what we are starting to see is the idea that the certification outcomes are not going to be sufficient to warrant enhanced funding matches from CMS. Practically, this means states should begin thinking critically about want they want out of their Medicaid IT procurements as they look to charter those efforts. 

We have even started to see CMS return funding and contracting vehicles to states with guidance that the outcomes aren’t really sufficiently conveying what tangible benefit the state hopes to achieve. Part of this challenge is understanding what an outcome actually is. States are used to describing those technical requirements, but those are really system outputs, not program outcomes.

What exactly is an outcome and what should states know when developing meaningful outcomes?

As states begin developing outcomes for their Medicaid IT projects, it will be important to distinguish between outcomes and outputs for the Medicaid program. If you think about programs, broadly speaking, they aim to achieve a desired outcome by taking inputs and resources, performing activities, and generating outputs.

As a practical example, we can think about the benefits associated with health and exercise programs. If a person wants to improve their overall health and wellbeing, they could enroll in a health and exercise program. By doing so, this person would likely need to acquire new resources, like healthy foods and exercise equipment. To put those resources to good use, this person would need to engage in physical exercise and other activities. These resources and activities will likely, over time, lead to improved outputs in that person’s heart rate, body weight, mood, sleeping patterns, etc.
 
In this example, the desired outcome is to improve the person’s overall health and wellbeing. This person could monitor their progress by measuring their heart rates over time, the amount of sleep they receive each night, or fluctuations in their body weight—among others. These outputs and metrics all support the desired outcome; however, none of the outputs alone improves this person’s health and wellbeing.

States should think of outcomes as the big-picture benefits they hope to achieve for the Medicaid program. Sample outcomes could include improved eligibility determination accuracy, increased data accessibility for beneficiaries, and timely management of fraud, waste, and abuse.
 
By contrast, outputs should be thought of as the immediate, direct result of the Medicaid program’s activities. One example of an output might be the amount of time required to enroll providers after their initial application. To develop meaningful outcomes for their Medicaid program, states will need to identify big-picture benefits, rather than immediate results. With this is mind, states can develop outcomes to demonstrate the value of their Medicaid IT systems and identify outputs that help achieve their desired outcomes.

What are some opportunities states have in developing outcomes for their MES modernizations?

The opportunities really begin with business process improvement. States can begin by taking a critical look at their current state business processes and understanding where their challenges are. Payment and enrollment error rates or program integrity-related challenges may be obvious starting points; however, drilling down further into the day-to-day can give an even more informed understanding of your business needs. Do your staff end users have manual and/or duplicative processes or even process workarounds (e.g., entering the same data multiple times, entering data into one system that already exists in another, using spreadsheets to track information because the MES can’t accommodate a new program, etc.)? Is there a high level of redundancy? Some of those types of questions start to get at the heart of meaningful improvement.

Additionally, states need to be aware of the people side of change. The shift toward an outcomes-based environment is likely going to place greater emphasis on organizational change management and development. In that way, states can look at how they prepare their workforce to optimize these new technologies.

The certification landscape is seemingly changing weekly as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team

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Outcomes and APD considerations

Read this if you’re considering (or in the middle of) an initiative that involves multiple Health and Human Services (HHS) programs or agencies.

During times of tight program budgets and rising need, the chance to collaborate with sister HHS agencies often presents a unique opportunity to do more with less. However, as you might find, these initiatives have their own challenges ranging from the minor (e.g., different program vocabulary) to major considerations (e.g., state and federal funding streams).

While interagency initiatives are worthwhile—usually aiming to reduce silos between HHS programs and better support citizens and staff—they can quickly grow complicated. Whether you’re just starting to think about your next interagency initiative or you’re halfway through, asking the right questions is half the battle. Answering those questions, of course, is the other—and more time-consuming—half!

In our team’s work with states on interagency initiatives, we have found it helpful to focus planning on the following four areas to minimize implementation timelines and maximize stakeholder support:

  • Policy: The sources, both internal and external, that govern who is covered by programs, what services are covered, how services are reimbursed, and how the program is administered
  • Funding: How a program is financed, including cost allocation methodologies, limitations on use of funds, and reporting mechanisms
  • Systems: The technical infrastructure that supports program operations
  • Operations: The staff and physical facilities that make every program possible, including staff resources such as training

Here are some questions you can ask to make the best use of available time, funding, and interagency relationships:

  • What is the goal? Do other departments or units have an aligning goal? Who do you know at those departments or units who could direct you to the best point of contact, the status of the other department or unit’s goal, and the current environment for change? Perhaps you can create a cross-unit team with the other unit(s), resulting in more resources to go around and stronger cross-unit relationships. If the other unit either isn’t ready or has already implemented its change, learning about the unit’s barriers or lessons learned will inform your efforts.
  • What does your governance model look like? Do you have one decision-maker or a consensus-builder leading a team? How does your governance model incorporate the right people from across all agencies so they have a voice? If the process is collaborative, can an oversight entity play a role in resolving disagreements or bottlenecks? Without a governance model, your team might be composed of subject matter experts (SMEs) who feel they do not have authority to make decisions, and the project could stall. On the other hand, if you only have leadership positions on the team without SME representation, the project plan might miss critical factors. Having the right people at the table—with defined lines of expertise, authority, and accountability—increases your chances of success.
  • Which federal partners are involved, who are the points of contact, and how open are they to this change? In addition to providing necessary approvals that could lead to funding, federal partners might offer lessons learned from other states, flexibilities for consideration, or even a pilot project to explore an initiative with you and your state partners. 
  • How will this initiative be funded? If more than one funding stream is available—for example, federal financial participation, grant dollars, state dollars—can (and should) all funding streams be utilized? What requirements, such as permissible use of funds and reporting, do you need to meet? Are these requirements truly required, or just how things have always been done? Some federal matches are higher than others, and some federal dollars can be combined while others must remain separate/mutually exclusive to be reimbursed. One approach for using multiple sources of funding is “braiding”—separate strands that, together, form a stronger strand—versus “blending,” which combines all sources into one pot of funding.
  • What systems are involved? After securing funding, system changes can be the largest barrier to a timely and effective interagency initiative. Many state agencies are already undertaking major system changes—and/or data quality and governance initiatives—which can be an advantage or disadvantage. To turn this into an advantage, consider how to proactively sync your initiative with the system or data initiative’s timing and scope.
     
    • When and how will you engage technical staff—state, vendor, or both—in the discussion?
    • Do these systems already exchange data? Are they modernized or legacy systems? 
    • Do you need to consult legal counsel regarding permissible data-sharing? 
    • Do your program(s)/agencies have a common data governance structure, or will that need to be built? 
    • What is the level of effort for system changes? Would your initiative conflict with other technical changes in the queue, and if so, how do you weigh priority with impacts to time and budget?
  • What policies and procedures will be impacted, both public-facing and internally? Are there differences in terminology that need to be resolved so everyone is speaking the same language? For example, the word “case” can mean something different for Medicaid business staff, child welfare staff, and technical staff.
  • Will this initiative result in fewer staff as roles are streamlined, or more staff if adding a new function or additional complexity? How will this be communicated and approved if necessary? While it’s critical to form a governance model and bring the right people to the table, it’s also imperative to consider long-term stakeholder structure, with an eye toward hiring new positions if needed and managing potential resistance in existing staff. For the project to have lasting impact, the project team must transition to a trained operations team and an ongoing governance model.

Ultimately, this checklist of considerations—goal-setting, decision-making, accountability, federal support, funding, systems, policies and procedures, and staffing—creates a blueprint for working across programs and funding streams to improve services, streamline processes, and better coordinate care.

For more information about interagency coordination, stay with us as we post more lessons learned on the following topics in the coming months: interagency policy, interagency funding, interagency systems, and interagency operations.
 

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Coordinating initiatives across state HHS: Questions to ask

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

This article is based on the Outcomes-Based Certification scalability and project outcomes podcast:


Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

How might Outcomes-Based Certification (OBC) be applied to more complex areas of the Medicaid enterprise?

The question of scaling—that is, to apply the OBC process to more complex components while maintaining or increasing its level of efficiency—is an important next step in certification. OBC has been (or is being) scaled across the technical components of the MES in two primary ways. First, OBC has already successfully been scaled horizontally across similar but discrete components of the MES such as electronic visit verification (EVV), provider management, or pharmacy. The second, perhaps more interesting way we are seeing OBC scale is vertically. OBC—or what is now being referred to as Streamlined Modular Certification (SMC)—is now being scaled up and into larger and more complex components like financial management and claims processing. Beyond that, however, we are now seeing outcomes-based concepts scale a third way—across the Medicaid business.

How does the certification of one module impact the rest of the MES?

We are seeing CMS and states work through this question every day. What we know for sure is that each state is likely going to draw its own set of boxes around its business modules and service components based on its Medicaid business. Because modularity is only defined at a macro level, states have the freedom to work with their vendors to define the parameters of their modules. As a result, we have seen CMS work with states to define those boxes and in doing so, we are really seeing a three-layered approach.

The first layer represents the primary module a state is certifying. A primary module is that module that is responsible for all or most of a business process such as paying a claim. It is safe to assume that the most detailed evidence will come from the primary module. The second layer represents the module—or modules—that might not have responsibility for a business process, but provide functionality integral to that business process being performed successfully. Finally, the third layer represents the module—or modules—that feed data into the business process, but do little else when it comes to performing that business process. For the second and third layer, a state can likely expect to provide evidence that supports the successful transmission of data at a minimum. This is where we are seeing CMS and states work together to define that scope.

What is the role of business process improvement, organization development, and organizational change management in MES modernizations?

This is really the cornerstone of this fundamental shift in certification we have seen over the last 12-18 months. During the 2020 virtual Medicaid Enterprise Systems Conference (MESC), we saw that CMS appears to be signaling it is no longer going to readily accept modernization efforts that do not reflect tangible improvements to the Medicaid business. Think about it this way: a state will likely not be able to go to CMS to request enhanced funding simply because it can no longer renew its existing contract vehicles or it is trying to procure new technology that fails to represent a marked improvement over its legacy system. 

As a result, states need to start thinking about reprocurement and modernization projects in terms of organizational development and business process improvement and redesign. What will a state get out of the new technology that they do not get today? That’s the question that needs to be answered. States should begin to focus more on business needs and less on technical requirements. States are used to building a custom, monolithic enterprise, often referred to as a Medicaid Management Information System (MMIS). Today, vendors are bringing commercial-off-the-shelf (COTS) products that allow states to perform business processes more efficiently. In turn, states need to move away from attempting to prescribe how a system should perform and focus on what the system should do. That means less prescriptive requirements and more business-oriented thinking.

Additionally, the concept of outcomes management will become integral to a state’s Advance Planning Document (APD) requests, Request for Proposals (RFP) development, and certification. We are seeing that CMS is beginning to look for outcomes in procurement documents, which is leading states to look critically at what they want to achieve as they seek to charter new projects. One way that a state can effectively incorporate outcomes management into its project development is to identify an outcome owner responsible for achieving those outcomes.

The certification landscape is seemingly changing weekly, as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team

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Scaling project outcomes