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Internal audit potential for
not-for-profit
organizations

By:

Colin is a Senior Consultant in BerryDunn’s Government Consulting Group with experience in communicating and executing strategic plans, coordinating membership development for various groups, and managing finance activities. He has worked on a wide range of projects with a focus on programmatic audit, forensic audit, financial process improvement, invoice review, and data analysis. He is a Certified Associate in Project Management and is currently working toward his Project Management Professional® certification.

Colin Buttarazzi
03.04.20

Editor’s note: Please read this if you are a not-for-profit board member, CFO, or any other decision maker within a not-for-profit.

In a time where not-for-profit (NFP) organizations struggle with limited resources and a small back office, it is important not to overlook internal audit procedures. Over the years, internal audit departments have been one of the first to be cut when budgets are tight. However, limited resources make these procedures all the more important in safeguarding the organization’s assets. Taking the time to perform strategic internal audit procedures can identify fraud, promote ethical behavior, help to monitor compliance, and identify inefficiencies. All of these lead to a more sustainable, ethical, and efficient organization. 

Internal audit approaches

The internal audit function can take on many different forms, depending on the size of the organization. There are options between the dedicated internal audit department and doing nothing whatsoever. For example:

  • A hybrid approach, where specific procedures are performed by an internal team, with other procedures outsourced. 
  • An ad hoc approach, where the board or management directs the work of a staff member.

The hybrid approach will allow the organization to hire specialists for more technical tasks, such as an in-depth financial analysis or IT risk assessment. It also recognizes internal staff may be best suited to handle certain internal audit functions within their scope of work or breadth of knowledge. This may add costs but allows you to perform these functions otherwise outside of your capacity without adding significant burden to staff. 

The ad hoc approach allows you to begin the work of internal audit, even on a small scale, without the startup time required in outsourcing the work. This approach utilizes internal staff for all functions directed by the board or management. This leads to the ad-hoc approach being more budget friendly as external consultants don’t need to be hired, though you will have to be wary of over burdening your staff.

With proper objectivity and oversight, you can perform these functions internally. To bring the process to your organization, first find a champion for the project (CFO, controller, compliance officer, etc.) to free up staff time and resources in order to perform these tasks and to see the work through to the end. Other steps to take include:

  1. Get the audit/finance committee on board to help communicate the value of the internal audit and review results of the work
  2. Identify specific times of year when these processes are less intrusive and won’t tax staff 
  3. Get involved in the risk management process to help identify where internal audit can best address the most significant risks at the organization
  4. Leverage others who have had success with these processes to improve process and implementation
  5. Create a timeline and maintain accountability for reporting and follow up of corrective actions

Once you have taken these steps, the next thing to look at (for your internal audit process) is a thoughtful and thorough risk assessment. This is key, as the risk assessment will help guide and focus the internal audit work of the organization in regard to what functions to prioritize. Even a targeted risk assessment can help, and an organization of any size can walk through a few transaction cycles (gift receipts or payroll, for example) and identify a step or two in the process that can be strengthened to prevent fraud, waste, and abuse.  

Here are a few examples of internal audit projects we have helped clients with:

  • Payroll analysis—in-depth process mapping of the payroll cycle to identify areas for improvement
  • Health and education facilities performance audit—analysis of various program policies and procedures to optimize for compliance
  • Agreed upon procedures engagement—contract and invoice/timesheet information review to ensure proper contractor selection and compliant billing and invoicing procedures 

Internal audits for companies of all sizes

Regardless of size, your organization can benefit from internal audit functions. Embracing internal audit will help increase organizational resilience and the ability to adapt to change, whether your organization performs internal audit functions internally, outsources them, or a combination of the two. For more information about how your company can benefit from an internal audit, or if you have questions, contact us

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  • Emily Parker
    Senior Manager
    Education, Healthcare, Not-For-Profit
    T 207.991.5182

Colin is a Senior Consultant in BerryDunn’s Government Consulting Group with experience in communicating and executing strategic plans, coordinating membership development for various groups, and managing finance activities. He has worked on a wide range of projects with a focus on programmatic audit, forensic audit, financial process improvement, invoice review, and data analysis. He is a Certified Associate in Project Management and is currently working toward his Project Management Professional® certification.

Professional
Colin Buttarazzi

Read this if you are at a rural health clinic or are considering developing one.

Section 130 of H.R. 133, the Consolidated Appropriations Act of 2021 (Covid Relief Package) has become law. The law includes the most comprehensive reforms of the Medicare RHC payment methodology since the mid-1990s. Aimed at providing a long-overdue payment increase to capped RHCs (freestanding and provider-based RHCs attached to hospitals greater than 50 beds), the provisions will simultaneously narrow the payment gap between capped and non-capped RHCs.

This will not obtain full “site neutrality” in payment as was a goal of CMS and the Trump administration, but the new provisions will help maintain budget neutrality with savings derived from previously uncapped RHCs funding the increase to capped providers and other Medicare payment mechanisms.

Highlights of the Section 130 provision:

  • The limit paid to freestanding RHCs and those attached to hospitals greater than 50 beds will increase to $100 beginning April 1, 2021 and escalate to $190 by 2028.
  • Any RHC, both freestanding and provider-based, will be deemed “new” if certified after 12/31/19 and subject to the new per-visit cap.
  • The above in effect eliminates uncapped cost-based reimbursement for provider-based RHCs certified subsequent to 12/31/19.
  • Grandfathering would be in place for uncapped provider-based RHCs in existence as of 12/31/19. These providers would receive their current All-Inclusive Rate (AIR) adjusted annually for MEI (Medicare Economic Index) or their actual costs for the year.

If you have any questions about your specific situation, please contact us. We’re here to help.

Article
Section 130 Rural Health Clinic (RHC) modernization: Highlights

Read this if your agency is involved with COVID-19 vaccination distribution.

Although states have already created COVID-19 vaccination plans, your state can still implement critical strategies to improve your distribution plan. In October 2020, the Centers for Disease Control (CDC) released the Interim Playbook version 2.0, providing a key framework for states and jurisdictions to build their COVID-19 vaccine distribution plans. The federal government asked that immunization programs in each state plans based on this model. The Playbook contains 15 sections of planning elements for states to consider in the development of their plan. Completing a plan of this extent while simultaneously trying to manage the pandemic has led some states to leave out or not thoroughly address critical components in their plans. 

The Kaiser Family Foundation (KFF) analyzed and collected common themes from each of the 47 state vaccination plans. Their analysis identified areas of weakness in the following areas of each plan: 

  • Priority populations for vaccinations in states 
  • Identifying networks of providers 
  • Developing data collection and reporting
  • Forming communication strategies

Each of the four areas each contained multiple findings, but since the vaccine has already started to roll out, some aspects of the plan cannot be revised. However, it is not too late to improve upon certain elements, especially for data collection and reporting, as well as communication strategies. 

The following recommendations for improvement of state plans are based on the findings from the KFF State COVID-19 vaccine distribution analysis report

States should identify a clear data reporting and collection plan that accounts for the COVID-19-specific data requirements.

According to KFF, an immunization registry or database has been included in 53% of the state COVID-19 plans; in the others it was an unclear component of the plan. The data collection process for COVID-19 vaccinations will be complex and unique due to a number of factors including the nature of a phased rollout, new provider enrollment and onboarding, storage requirements, multiple vaccines and doses, and off-site vaccination locations

Since a little over half of all states have arranged for either new systems or are developing or adding features to current immunization registries, states that are lacking a comprehensive approach could benefit from adopting elements present in the other plans. For example, some states detail how their current immunization system is being utilized for the COVID-19 vaccine, in addition to upgrading certain features in order to meet the anticipated increase in demand. 

Other states have also described their transition to the Immunization Gateway, a centralized technical infrastructure sponsored by the CDC Immunization Information Systems Support Branch, and led by the US Department of Health and Human Services Office of the Chief Technology Officer. The Gateway is securely hosted through the Association of Public Health Laboratories (APHL). States can review the data collection and reporting sections of other states’ plans to gain a greater understanding of how their plan can be improved by describing data reporting and collection processes.   

States should address racial and ethnic disparities in vaccine distribution and acceptance through targeted and evidence-based communication strategies. 

The KFF analysis of state COVID-19 plans indicated about 49% of state plans include specific mention of racial or ethnic minority populations in regards to communication. Communication plans need to include targeted strategies as minority populations and people of color have shown greater hesitation in receiving the vaccine, even if it is free and determined safe by scientists and federal authorities. The virus has had a disproportionate impact on communities of color and minority populations, and a lack of communication to these populations may continue to enhance these disparate health outcomes.

One way to improve a communication plan by addressing racial or ethnic minority populations would be by incorporating the National Standards for Culturally and Linguistically Appropriate Services (CLAS), specifically the standards for Communication and Language Assistance:

  • Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services
  • Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing
  • Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided
  • Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area

A communication plan that considers the racial and ethnic minority populations most vulnerable to adverse health outcomes and have shown a lack of trust in the scientific community would be advisable in order to combat disproportionate negative outcomes from the COVID-19 virus in the future. 

A COVID-19 vaccine distribution plan is an important aspect of each state’s strategy to control the spread of the virus. In order to lead to effective vaccine distribution, it is vital for the plans to thoroughly address data collection, reporting, and tracking. It is also important to consider implementing a communication plan that incorporates strategies to reach racial and ethnic minority groups who might have been disproportionality impacted by COVID-19 as a way to improve your state’s health equity approach to COVID-19 vaccination efforts. By implementing these considerations, your state’s COVID-19 vaccine distribution plan could become more effective in improving the health outcomes of your population. 

Article
Two ways states can improve their COVID-19 vaccination distribution plans

Read this if you are a business owner or interested in upcoming changes to current tax law.

As Joe Biden prepares to be inaugurated as the 46th President of the United States, and Congress is now controlled by Democrats, his tax policy takes center stage.

Although the Democrats hold the presidency and both houses of Congress for the next two years, any changes in tax law may still have to be passed through budget reconciliation, because 60 votes in the Senate generally are needed to avoid that process. Both in 2017 and 2001, passing tax legislation through reconciliation meant that most of the changes were not permanent; that is, they expired within the 10-year budget window. Here is a comparison of current tax law with Biden’s proposed tax plan.

Current Tax Law
(TCJA–present)
Biden’s stated goals
Corporate tax rates and AMT

Corporations have a flat 21% tax rate and no corporate alternative minimum tax (AMT), which were both changed by the TCJA.

These do not expire.

Biden would raise the flat rate to the pre-TCJA level of 28% and reinstate the corporate AMT, requiring corporations to pay the greater of their regular corporate income tax or the 15% minimum tax (while still allowing for net operating loss (NOL) and foreign tax credits).

Capital gains and Qualified Dividend Income

The top tax rate is 20% for income over $441,450 for individuals and $496,600 for married filing jointly. There is an additional 3.8% net investment income tax.

Biden would eliminate breaks for long-term capital gains and dividends for income above $1 million. Instead, these would be taxed at ordinary rates.

Payroll taxes

The 12.4% payroll tax is divided evenly between employers and employees and applies to the first $137,700 of an individual’s income (scheduled to go up to $142,400 in 2020). There is also a 2.9% Medicare Tax which is split equally between the employer and the employee with no income limit.

Biden would maintain the 12.4% tax split between employers and employees and keep the $142,400 cap but would institute the tax on earned income above $400,000. The gap between the two wage levels would gradually close with annual inflationary increases.

International taxes (GILTI, offshoring)

GILTI (Global Intangible Low-Tax Income): Established by the TCJA, U.S. multinationals are required to pay a foreign tax rate of between 10.5% and 13.125%.

A scheduled increase in the effective rate to 16.406% is scheduled to begin in 2026.

Offshoring taxes: The TCJA includes a tax deduction for corporations that manufacture in the U.S. and sell overseas.

GILTI: Biden would double the tax rate to 21% and assess a minimum tax on a country-by-country basis.

Offshoring taxes: Biden would establish a 10% penalty surtax on profits for goods and services manufactured offshore and a 10% advanceable “Made in America” tax credit to create U.S. manufacturing jobs. Biden would also close offshoring tax loopholes in the TCJA.

Estate taxes

The estate tax exemption for 2020 is $11,580,000. Transfers of appreciated property at death get a step-up in basis.

The exemption is scheduled to revert to pre-TCJA levels.

Biden would return the estate tax to 2009 levels, eliminate the current step-up in basis on inherited assets, and eliminate the step-up at death provision for inherited property passed along by the decedent.

Individual tax rates

The top marginal rate is 37% for income over $518,400 for individuals and $622,050 for married filing jointly. This was lowered from 39.6% pre-TCJA.

Biden would restore the 39.6% rate for taxable income above $400,000. This represents only the top rate.

Individual tax credits

Currently, individuals can claim a maximum of $2,000 Child Tax Credit (CTC) plus a $500 dependent credit.

Individuals may claim a maximum dependent care credit of $600 ($1,200 for two or more children).

The CTC is scheduled to revert to pre-TCJA levels ($1,000) after 2025.

Biden would expand the CTC to $3,000 for children age 17 and under and offer a $600 bonus for children age 6 and under. It would also be fully refundable.

He has also proposed increasing the child and dependent care tax credit to $8,000 ($16,000 for two or more children), and he has proposed a new tax credit of up to $5,000 for informal caregivers.

Separately, Biden has also proposed a $15,000 tax credit for first-time homebuyers.

Qualified Business Income Deduction under Section 199A

As previously discussed, many businesses qualify for a 20% qualified business income tax deduction lowering the effective rate of tax for S corporation shareholders and partners in partnerships to 29.6% for qualifying businesses.

Biden would phase out the tax benefits associated with the qualified business income deduction for those making more than $400,000 annually.

Education

Forgiven student loan debt is included in taxable income.

There is no tax credit for contributions to state-authorized organizations that sponsor scholarships.

Biden would exclude forgiven student loan debt from taxable income.

Small businesses

There are current tax credits for some of the costs to start a retirement plan.

Biden would offer tax credits for businesses that adopt a retirement savings plan and offer most workers without a pension or 401(k) access to an “automatic 401(k)”.

Itemized deductions

For 2020, the standard deduction is $12,400 for single/married filing separately and $24,800 for married filing jointly.

After 2025, the standard deduction is scheduled to revert to pre-TCJA amounts, or $6,350 for single /married filing separately and $12,700 for married filing jointly.

The TCJA suspended the personal exemption and most individual deductions through 2025.

It also capped the SALT deduction at $10,000, which will remain in place until 2025, unless repealed.

Biden would enact a provision that would cap the tax benefit of itemized deductions at 28%.

SALT cap: Senate minority leader Charles Schumer has pledged to repeal the cap should Biden win in November (the House of Representatives has already passed legislation to repeal the SALT cap).

Opportunity Zones

Biden has proposed incentivizing - opportunity zone funds to partner with community organizations and have the Treasury Department review the program’s regulations of the tax incentives. He would also increase reporting and public disclosure requirements.
Alternative energy Biden would expand renewable energy tax credits and credits for residential energy efficiency and restore the Energy Investment Tax Credit (ITC) and the Electric Vehicle Tax Credit.


If you have questions about your specific situation, please contact us. We’re here to help.

Article
Biden's tax plan and what may change from current tax law

Read this if your company is seeking guidance on PPP loans.

The Consolidated Appropriations Act, 2021 (H.R. 133) was signed into law on December 27, 2020. This bill contains guidance on the existing Paycheck Protection Program (PPP) and guidelines for the next round of PPP funding.

Updates on existing PPP loans

Income and expense treatment of PPP loans. Forgiven PPP loans will not be included in taxable income and eligible expenses paid with PPP funds will be tax-deductible. This tax treatment applies to both current and future PPP loans.

Tax attributes and basis adjustments. Tax attributes such as net operating losses and passive loss carryovers, and basis increases generated from the result of the PPP loans will not be reduced if the loans are forgiven.

Economic Injury Disaster Loans (EIDL). Any previous or future EIDL advance will not reduce PPP loan forgiveness. Any borrowers who already received forgiveness of their PPP loans and had their EIDL subtracted from the forgiveness amount will be able to file an amended forgiveness application to have their PPP forgiveness amount increased by the amount of the EIDL advance. The SBA has 15 days from the effective date of this bill to produce an amended forgiveness application. 

Simplified forgiveness application for loans under $150,000. Borrowers who received PPP loans for $150,000 or less will now be able to file a simplified one-page forgiveness application and will not be required to submit documentation with the application. The SBA has 24 days from the effective date of this bill to make this new forgiveness application available. 

Use of PPP funds. Congress expanded the types of expenses that may be paid with PPP funds. Prior eligible expenses were limited to payroll (including health benefits), rent, covered mortgage interest, and utilities. Additional expenses now include software and cloud computing services to support business operations, the purchase of essential goods from suppliers, and expenditures for complying with government guidance relating to COVID-19.

These additional expenses apply to both existing and new PPP loans, but they do not apply to existing loans if forgiveness has already been obtained.
 
In addition, the definition of "payroll costs" has been expanded to include costs for group life, disability, dental, and vision insurance. These additions also apply to both existing and new loans.

Information for new PPP loans

Application deadline. March 31, 2021 

Eligibility for first-time borrowers. A business that did not previously apply for or receive a PPP loan may apply for a new loan. The same requirements apply from the first round of loans. The business must employ fewer than 500 employees per physical location and the borrower must certify the loan is necessary due to economic uncertainty.

Eligibility for second-time borrowers. Businesses that received a prior PPP loan may apply for a second loan, however the eligibility requirements are a little more stringent. The business must have fewer than 300 employees per physical location (down from 500 previously) and it must have experienced a decline in gross revenue of at least 25% in any quarter in 2020 as compared to the same quarter in 2019. The business must have also expended (or will expend) their initial PPP loan proceeds. 

Maximum loan amount. Lesser of $2 million or 2.5x average monthly payroll for either calendar 2019 or the 12-month period prior to the date of the loan. Businesses operating in the accommodations and food service industry (NAICS code 72) can use a 3.5x average monthly payroll multiple. If the business previously received a loan less than the new amount allowed, or if it returned a portion or all of the previous loan, it can apply for additional funds up to the maximum loan amount. 

New types of businesses eligible for loans.

  • Broadcast news stations, radio stations, and newspapers that will use the proceeds to support the production and distribution of local and emergency information 
  • Certain 501(c)(6) organizations with fewer than 300 employees and that are not significantly involved in lobbying activities 
  • Housing cooperatives with fewer than 300 employees 
  • Companies in bankruptcy if the bankruptcy court approves

Ineligible businesses. A business that was ineligible to receive a PPP loan during the first round is still ineligible to receive a loan in the new round. The new legislation also prohibits the following businesses from receiving a loan in the second round:

  • Publicly traded companies 
  • Businesses owned 20% or more by a Chinese or Hong Kong entity or have a resident of China on its board 
  • Businesses engaged primarily in political or lobbying activities
  • Businesses required to register under the Foreign Agents Registration Act 
  • Businesses not in operation on February 15, 2020 

Forgiveness qualifications. New PPP loans will be eligible for forgiveness if at least 60% of the proceeds are used on payroll costs. Partial forgiveness will still be available if less than 60% of the funds are used on payroll costs. 

Covered period. The borrower may choose a covered period (i.e., the amount of time in which the PPP funds must be spent) between 8 and 24 weeks from the date of the loan disbursement.

Employee Retention Tax Credit. The CARES Act prohibited a business from claiming the Employee Retention Tax Credit if they received a PPP loan. The new legislation retroactively repeals that prohibition, although it is unclear how an employer can claim retroactive relief. The new bill also expands the tax credit for 2021. 

Additional guidance is expected from the SBA in the coming weeks on many of these items and we will provide updates when the information is released.

We’re here to help.
If you have questions about PPP loans, contact a BerryDunn professional.

Article
Paycheck Protection Program: Updates on new and existing loans

Read this if your facility or organization has received provider relief funds.

The rules over the use of the provider relief funds (PRF) have been in a constant state of flux since the funds started to show up in your bank accounts back in April. Here is a summary of where we are as of November 30, 2020 with allowable uses of the funds.
 
The most recent Post-Payment Notice of Reporting Requirements is dated November 2, 2020. In accordance with the notice, PRF may be used for two purposes:

  1. Healthcare-related expenses attributable to coronavirus that another source has not reimbursed and is not obligated to reimburse
  2. Lost revenue, up to the amount of the difference between 2019 and 2020 actual patient care revenue

The Department of Health and Human Services (HHS) has issued FAQs as recently as November 18, 2020.  The FAQs include the following clarifications on the allowable uses:

Healthcare related expenses attributable to the coronavirus

  1. PRF may be used for the marginal increased expenses or incremental expenses related to coronavirus.
  2. Expenses cannot be reimbursed by another source or another source cannot be obligated to reimburse the expense.
  3. Other sources include, but are not limited to, direct patient billing, commercial insurance, Medicare/Medicaid/Children’s Health Insurance Program (CHIP), or other funds received from the Federal Emergency Management Agency (FEMA), the Provider Relief Fund COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured, and the Small Business Administration (SBA) and Department of Treasury’s Paycheck Protection Program (PPP). This would also include any state and federal grants received as a result of the coronavirus.
  4. Providers should apply reasonable assumptions when estimating the portion of costs that are reimbursed from other sources.
  5. The examples in the FAQs for increased cost of an office visit and patient billing seem to point to only supplemental coronavirus related reimbursement needing to be offset against the increased expense.
  6. PRF may be used for the full cost of equipment or facility projects if the purchase was directly related to preventing, preparing for and responding to the coronavirus; however, if you claim the full cost, you cannot also claim the depreciation for any items capitalized.
  7. PRF cannot be used to pay salaries at a rate in excess of Executive Level II which is currently set at $197,300.

Lost revenues attributable to the coronavirus

  1. Lost revenues attributable to coronavirus are calculated based upon a calendar year comparison of 2019 to 2020 actual revenue/net charges from patient care (prior to netting with expenses).
  2. Any unexpended PRF at 12/31/20 is then eligible for use through June 30, 2021 and calculated lost revenues in 2021 are compared to January to June 2019.
  3. Reported patient care revenue is net of uncollectible patient service revenue recognized as bad debts and includes 340B contract pharmacy revenue.
  4. This comparison is cumulative, for example, if your net income improves in Q4, it will reduce lost revenues from Q2.
  5. Retroactive cost report settlements or other payments received that are not related to care provided in 2019 or 2020 can be excluded from the calculation.

Whether you are tracking expenses or lost revenues, the accounting treatment for both is to be consistent with your normal basis of accounting (cash or accrual).
 
As a reminder, the first reporting period (through December 31, 2020) is due February 15, 2021. The reporting portal is supposed to open January 15, 2021. Any unexpended PRF at December 31, 2020 can be used from January 1, 2021 through June 30, 2021, with final reporting due July 31, 2021.

The guidance continues to change rapidly and new FAQs are issued each week. Please check back here for any updates, or contact Mary Dowes for more information.

Article
Provider relief funds: Allowable uses 

Read this if you are a director or manager at a Health and Human Services agency in charge of modernizing your state's Health and Human Services systems. 

When states start to look at outdated Health and Human Services systems like Eligibility Systems or Medicaid Enterprise Systems, they spend a lot of time on strategic planning efforts and addressing technology deficiencies that set the direction for their agencies. While they pay a lot of attention to the technology aspects of the work, they often overlook others. Here are three to pay attention to: 

  1. Business process improvement
  2. Organization development
  3. Organizational change management

Including these important steps in strategic planning often improves the likelihood of an implementation of Health and Human Service systems that provide the fully intended value or benefit to the citizen they help serve. When planning major system improvements, agencies need to have the courage to ask other critical questions that, when answered, will help guarantee greater success upon implementation of modernized system.

Don’t forget, it’s not only about new technology—it’s about gaining efficiencies in your business processes, structuring your organization in a manner that supports business process improvements, and helping the people in your organization and external stakeholders accept change.  

Business process improvement 

When thinking about improving business processes, a major consideration is to identify what processes can be improved to save time and money, and deliver services to those in need faster. When organizations experience inefficiencies in their business processes, more often than not the underlying processes and systems are at fault, not the people. Determining which processes require improvement can be challenging. However, analyzing your business processes is a key factor in strategic planning, understanding the challenges in existing processes and their underlying causes, and developing solutions to eliminate or mitigate those causes are essential to business process improvement.

Once you pinpoint areas of process improvement, you can move forward with reviewing your organization, classifying needs for potential organization development, and begin developing requirements for the change your organization needs.

Organization development

An ideal organizational structure fully aligns with the mission, vision, values, goals, and strategy of an organization. One question to ask when considering the need for organization development is, “What does your organization need to look like to support your state’s to-be vision?” Answering this question can provide a roadmap that helps you achieve:

  1. Improved outcomes for vulnerable populations, such as those receiving Medicaid, TANF, SNAP, or other Health and Human Services benefits 
  2. Positive impacts on social determinants of health in the state
  3. Significant cost savings through a more leveraged workforce and consolidated offices with related fixed expenses—and turning focus to organizational change management

Organization development does not stop at reviewing an organization’s structure. It should include reviewing job design, cultural changes, training systems, team design, and human resource systems. Organizational change is inherent in organization development, which involves integration of a change management strategy. When working through organization development, consideration of the need for organizational change should be included in both resource development and as part of the cultural shift.

Organizational change management

Diverging from the norm can be an intimidating prospect for many people. Within your organization, you likely have diverse team members who have different perspectives about change. Some team members will be willing to accept change easily, some will see the positive outcomes from change, but have reservations about learning a new way of approaching their jobs, and there will be others who are completely resistant to change. 

Successful organizational change management happens by allowing team members to understand why the organization needs to change. Leaders can help staff gain this understanding by explaining the urgency for change that might include:

  • Aging technology: Outdated systems sometimes have difficulty transmitting data or completing simple automated tasks.
  • Outdated processes: “Because we’ve always done it this way” is a red flag, and a good reason to examine processes and possibly help alleviate stressors created by day-to-day tasks. It might also allow your organization to take care of some vital projects that had been neglected because before there wasn’t time to address them as a result of outdated processes taking longer than necessary.
  • Barriers to efficiency: Duplicative processes caused by lack of communication between departments within the organization, refusal to change, or lack of training can all lead to less efficiency.

To help remove stakeholder resistance to change and increase excitement (and adoption) around new initiatives, you must make constant communication and training an integral component of your strategic plan. 

Investing in business process improvement, organization development, and organizational change management will help your state obtain the intended value and benefits from technology investments and most importantly, better serve citizens in need. 

Does your organization have interest in learning more about how to help obtain the fully intended value and benefits from your technology investments? Contact our Health and Human Services consulting team to talk about how you can incorporate business process improvement, organization development, and organizational change management activities into your strategic planning efforts.

Article
People and processes: Planning health and human services IT systems modernization to improve outcomes

Read this if you are a member of a State Medicaid Agency’s leadership team.

Another National Association of Medicaid Directors (NAMD) fall conference is in the books. As usual, the sessions were excellent. And this year we had the luxury of being able to attend from the comfort of our homes. For BerryDunn’s consulting group, that enabled us to “send” a broader team to conference. On the flip side, it also meant we were not able to greet and meet our community in person. 

Matt Salo, the NAMD Executive Director, defined the underlying themes to the conference as Flexibility, Innovation, and Resilience. If one were to just look at the full agenda, it would be hard to tell that this was a virtual conference. The session schedule and opening reception looked very much like a traditional NAMD conference, although there were not the usual breaks with the ice cream jubilee and ballroom number assignments. Otherwise, it was business as usual. 

In checking in with State Medicaid Director attendees, Monday’s meetings went well and they appreciated coming together. State leadership across the country is working straight-out right now—seven days a week. It kind of reminds me of when I became a parent: I thought I knew how to handle sleep deprivation, and then I had a newborn, and realized the important work of parenting isn’t on a time clock, which is much like the work Medicaid agencies are dedicated to. The directors and their support staff’s commitment to serving members and tax payers in their respective states is inspiring, and we are privileged to work alongside them. 

I appreciated a subtle but deep reminder from Matt and the NAMD President Beth Kidder for us: remember our “true North.” Why are we here? What is our purpose as leaders and vendors in the Medicaid community? The work we do matters. We can improve lives. We can save lives. The members in Medicaid programs are the center of all we do. Here are some of the other highlights I absorbed during the conference. 

Plenary sessions

In Tuesday’s plenary, panelists shared their primary lessons and reflections on the year, including: 

  • Pace―we need a balance because the pandemic does not have a clear beginning or end. Pandemics do not simply blow over like a hurricane; it’s hard to tell the beginning, middle, and end. 
  • Steadiness in chaos: velocity and stability―leaders need to make timely decisions while also being an anchor for their teams. 
  • Prioritization―not everything needs an immediate response. We need to be deliberate about what we do. 
  • Roadmaps―we can still use the tools we created map out where we want to go. 

The panel also shared how telehealth, transparency, teamwork, focus, and reflecting on “whole lives” in policy making assisted them in navigating their teams and providing the best services possible. 

Keynote―health equity 

Dayna Bowen Matthew provided a solid argument on how Medicaid can be key to achieving true health equity in America. She discussed the four “Ps” that can make this possible: Population, Position, Payer, and Persuader. She used the COVID-19 pandemic as her example of how it hit the vulnerable population first, and how we could have learned from it. 

Instead, it is being unleashed on the broader population. The work must begin with us, expand to our teams, policies we can control, and then policies that need a collaborative approach to change and implement. If you attended the conference and have access but missed this talk, I highly recommend listening to it as she covered a lot of very pertinent material. 

Member perspectives 

Sprinkled through the entire conference were videos of Medicaid members’ perspectives. I appreciate the tradition of bringing the human element of Medicaid’s impact into the conference, as it reminds us of our purpose. The perspectives also underscore another important theme of Matt’s: “Medicaid is a program about people, not statistics.” Examples of stories we heard include how someone went from 28 years of incarceration due to an armed robbery conviction to graduating from a university and now working with people; a hockey coach’s accident that paralyzed him from the neck down; a homeless mother gaining security and stability; a foster parent with a son having a rare brittle bone disease and a Native American parent with health access issues. 

Economy 

There were a couple of sessions related the economy, and generally, the presenters thought the biggest impact to Medicaid is yet to come. They said that there is typically a lag between events and member enrollments and the surge is still coming. They also agreed there was strong federal support from outside of CMS that kept their enrollment down. Membership growth is likely coming as state budgets are constrained. There are hopes for additional federal assistance within Medicaid, including an extended FMAP, and a similar package from last spring. The lack of certainty in regards to consistent funding is causing the states to spend a lot of energy developing back up plans. 

The panelists think the biggest economic challenges are yet to come is based upon three main reasons: the high chance of a recession, the impending (third wave) virus impact, and the social unrest exacerbated by the pandemic and systemic racism. These are merging perfect storms causing directors to look for stability and relief. I think the best summary I heard of how to proceed was open the book of “good ideas for bad times” that were not well thought of during good times. 

Public health emergency―COVID-19 pandemic 

As would be expected, COVID was a recurring topic in almost every session. There was a very interesting panel discussion on how best to “unwind” the changes made once we arrive in the post-pandemic era. There will be lots of challenges, and it is worth discussing these now, while we are still in the midst of responding to the immediate needs to address the virus. We are aware there will be systemic and program reversals. However, it will not be as simple as just doing a rollback. States will need to develop their strategies for redeterminations of their member populations and the timing will need to be coordinated. CMS will need to prepare guidance on expectations for unwinding. Programs will need to be reviewed and decisions prioritized on what needs to be changed. 

Prior to getting to post-pandemic era, states know they will need to plan for managing vaccine distribution, which will be one tool to help bring the curve down. According to former senior officials from the Trump and Obama administrations, the worst pandemic phase is coming this winter. However, there is “light at the end of the tunnel” because of optimism on a vaccine and other tools. We know more in this upcoming wave than the first wave in March. According to these officials, the sciences cannot get us through without a human element. And the human element can save a lot of lives. 

As Scott Gottlieb, MD, former FDA Commissioner, said, “We just need to stop breathing on each other.” He was implying that we need to socially distance and wear masks, while we wait for the vaccine come around and be distributed. The challenge is, according to Andy Slavitt, Former Acting Administrator for CMS, that the vaccine will not be available to the majority of the population for two to three months, and by then, if humans do not continue to change behavior, the spread could go to 30-40% of the population. They predict the pandemic will be at its worst point when the vaccine is made available. 

Seema Verma, the CMS Administrator, said the PHE has shown that we have the ability to work faster. She wants to ensure we heed the lessons of the pandemic, and in particular the experiences with the spread and deaths in the nursing homes. She feels that the issues in the nursing facilities cannot be fixed at the federal level. She sees CMS’s role is to encourage innovation at the state level, while the federal government hold states accountable to costs and positive outcomes and quality. 

Other concerns panelists raised regarding the pandemic are the long-term and downstream ripple effects of responding to the pandemic. For example: 

  • States know their members have delayed, deferred, and simply foregone healthcare over these past several months. This will create a surge in treatment at a later date, causing increased demand to an already fatigued provider community.
  • The reduced health of the general population resulting from not receiving the right care now and delaying care will further harm the well-being of the population. 
  • Our education system has gone mostly online, adversely impacting students’ ability to learn. 
  • The overall mental health of our population is at risk—the pandemic has changed all of us, and we will learn to what extent it is harmed us over the next several years. 

Looking ahead―there is hope

Several of the panels spent time discussing what our future might look like. It was encouraging to hear how there is a vision for long-term care delivery changes, meeting behavioral health needs, emergency and pandemic preparedness approaches, and addressing workforce challenges and healthcare inequalities. When asked to name one or two words that will represent where we are in five years, the panelists said: 

  • Lead and Succeed (#leadandsucceed) 
  • Survive and Thrive (#surviveandthrive) 
  • Even Better Together (#evenbettertogether)

We are in this today, and we are together, keeping the eye on our “true North”. Doing so will help us remain together and make us stronger in the future. The key is that we remain together. The conference showed that even though we could not be together in the same geographic place, our minds, attention, and spirit are aligned. We experienced the spirit of NAMD from our homes. 

We know that the future holds opportunities for us to be physically together in the future. We missed being in DC this year, and are very hopeful we will see you next year. That will be icing on the cake, which we will savor and not take for granted. Until then, I am confident we will maintain our integrity and focus on our purpose. 
 

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NAMD 2020 reflections: Together towards the future