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NAMD 2020 reflections: Together towards the future

11.16.20

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. 
 

Related Industries

Related Professionals

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

Monday’s NESCSO-hosted conversation was a breath of fresh air in our COVID-19 work-from-home experience. Seeing familiar faces presenting from their home offices reminded me that, yes, we are truly all in this together—working remotely, and focused on how best to foster an efficient and effective Medicaid program for our state clients and members. Over the past several years I have written a “Reflections” blog, summarizing the week-long MESC event while flying home. Today, I am posting my reflections on the first forum NESCSO sponsored in lieu of their August conference that was cancelled this year due to the global pandemic. Following are my major takeaways.

The main speakers were Karen Shields, Deputy Director from the Center for Medicaid and CHIP Services, and Julie Boughn, Director, Data Systems Group also for the Center for Medicaid and CHIP Services. There were several other guests that joined in this two-hour forum, some from the Data Systems Group, and some from the states.

Crisis as a learning tool

Karen Shields reinforced that we will be better and stronger as a result of the crisis that faces us, and encourages us to use the current crisis as a learning tool. She stressed the importance of how we are leveraging our creativity and innovation to keep moving forward. She said to start with the end in mind, be a team player, and keep in mind these three important points of focus for CMS:

  1. Share what works, share what doesn’t. Prioritize.
  2. Systems development needs to be agile. Partnership is critical. States needs to be “elbow deep” with others. Everyone is allowed to speak. 
  3. Re-usability is key! Push back on those who say we cannot reuse.

During the Q&A session, Karen discussed how to maintain consistency by turning to action and using lessons learned. Resist the urge to “fall back.” Let’s keep moving forward. She underscored how they will continue the all-state calls as there are lots of topics and conversations needed to explore deficits of need. 

Support systems and policies

Julie Boughn opened by stressing what an important layer of support systems provide policies. She said COVID is not a system issue—the systems supporting the approach to address the virus are working and a big part of contributing to helping alleviate the issues the pandemic presents. She noted an appropriate quip that “Without systems, policies are just interesting ideas on pieces of paper.”

She underscored that healthcare and all that goes with supporting it is never static. The Medicaid arena is in a world of increasing change, requiring the supporting systems to adapt to make payments correctly and facilitate the provision of benefits to the right people. CMS has been focused on, and continues to bring our focus to outcomes, especially in the IT investments being made. Promote sharing and re-use of those investments.

During the Q&A, Julie reinforced the priority on outcomes and spoke to outcomes-based certification (OBC). There was a question on “What happens to modularity in the context of OBC?” She said that they are completely compatible and naturally modular, and to think about how a house can be built but not be completely done. Build the house in chunks of work, and know what you’re achieving with each “chunk”. Outcomes are behind everything we do.

Engage with your federal partners

In the next presentation, CMS modeled a dialogue that demonstrated how states can engage with their federal partners. CMS wants to continue changing the relationship they have with states. They also reminded the audience of what CMS is looking for; as Ed Dolly, the Director for the Division of State Systems within the Data and Systems Group said during the conversation, “Do you understand the problem trying to be solved?” Define your final outcome, and understand that incremental change drives value. In addition to communicating the problem, focus on speed of delivery (timeliness), and engage in back and forth exchange on what best measures can be used, as well as the abilities to capture the measures to report progress. The bottom line?  “When in doubt, reach out!”

The remainder of the forum featured representatives from the State System Technology Advisory Group (S-TAG), Private Sector Technology Group (PSTG), and Human Services Information Technology IT Advisory Group (HSITAG). They discussed a variety of IT topics.

Technology outlook

The S-TAG had representation from an impressive list of states—West Virginia, Washington, Wyoming, Vermont, and Massachusetts. They spoke to how they envision their technology response to changes in policy now and in the next 12-18 months. There was too much to present here, and I recommend reviewing the recording once NESCSO posts it. Initiatives included: Provider enrollment, electronic asset verification, electronic visit verification, integrated eligibility systems, modularity implementations, migration to the cloud, pharmacy systems, system integrator, certification, strategic planning, electronic data interchange upgrades, payment reform, road map activities, case management, care management, T-MSIS, and HITECH.

HSITAG spoke about the view across the health and human services spectrum—Where are we today? Where will we be tomorrow? COVID has tested our IT infrastructure and policy. Is there an ability to quickly scale up? Weaknesses in interoperability became exposed and while it seemed Medicaid was spared in the headlines, the need to modernize is now much more apparent. Modularity showed its value in more timely implementations. There is concern over an upcoming increase in the Medicaid population. Are we equipped for the short term?

For the long-run, where we will be “tomorrow” in the 12-18 month view, there will be a bigger dependency on the interrelations between all programs. Medicaid Enterprise Systems can and should look at whole systems, focusing on social determinants of health. Data and program integrity will be key, as the increased potential of fraud in the midst of challenging state budgets. We will need to respond quickly with limited resources.

Keep relationships strong

PSTG spoke of how when COVID hit, it caused them, like the rest of us, to modify their goals. They spoke about relationships and the importance of maintaining them with clients and colleagues, questions of productivity, what things that we have learned will we carry into the post-pandemic era, will we remain flexible, and how will we “unwind” all the related changes that will not be carried forward. Looking forward, PSTG wants to support the growing of the outcomes-based culture, evolve the state self-assessment (currently an active workgroup), and how to be less prescriptive to allow for more flexibility on “how” vendors get to solutions.

I was grateful to be able to join this event, and hear that we are in this together—we will get through it and we will keep moving forward. I felt this was a good start to what I hope will be the first of many MESC 2020 forums. The session felt like it ended too quickly even though we covered a lot of ground. I am excited about the thought of hearing about new ideas, improving our understanding of upcoming changes CMS is sponsoring, and engaging in the innovative thought that will keep us moving toward a better tomorrow. Thanks to NESCSO for sponsoring this event and bringing us together.

Please contact our Medicaid Consulting team for more information on if you have any questions.

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MESC 2020: Where we are today and where we will be tomorrow

Phew! We did it—The Medicaid Enterprise Systems Conference (MESC) 2019 is one for the books! And, it was a great one. Here is my perspective on objectives and themes that will guide our work for the year.

Monday 

My day started in the fog—I live on an island in Maine, take a boat to get into Portland, and taxi to the airport. Luckily, I got to Portland, and, ultimately Chicago, on time and ready to go. 

Public Sector Technology Group (PSTG) meeting

At the PSTG meetings, we reviewed activities from the previous year and did some planning for the coming year. Areas for consideration included:

  • Modernization Schedule
  • Module Definitions
  • Request for Proposal (RFP) Requirements
  • National Association of State Procurement Officers

Julie Boughn, Centers for Medicare and Medicaid (CMS) Director, Data and Systems Group (DSG) introduced her new boss, Karen Shields, who is the Deputy Director for the Center for Medicaid and CHIP Services (CMCS) within CMS. Karen shared her words of wisdom and encouragement with us, while Julie reminded us that being successful in our work is about the people. CMS also underscored the goal of speeding up delivery of service to the Medicaid program and asking ourselves: “What is the problem we are trying to resolve?” 

CMS’ “You be the State” officer workshop

Kudos to CMS for creating this open environment of knowledge sharing and gathering input.  Areas for discussion and input included:

  • APD Processes
  • Outcomes-Based Certification
  • Increasing and Enhancing Accountability

Tuesday
Opening Plenary

I was very touched by the Girls Inc. video describing the mission of Girls Inc. to inspire girls to be strong, smart, and bold. With organizations like this, and our awareness and action, I am optimistic for the future. Thank you to NESCSO for including this in their opening program.

John Doerr, author of Measure What Matters: OKRs: The Simple Idea that Drives 10x Growth and famed investor, shared his thoughts on how to create focus and efficiency in what we do. Julie’s interview with him was excellent, and I appreciated how John’s Objectives and Key Results (OKR) process prompted Julie to create objectives for what we are trying to do. The objectives Julie shared with us:

  • Improve the quality of our services for users and other stakeholders 
  • Ensure high-quality data is available to manage the program and improve policy making 
  • Improve procurement and delivery of Medicaid technology projects

Sessions

The sessions were well attended and although I can't detail each specific session I attended, I will note that I did enjoy using the app to guide me through the conference. NESCSO has uploaded the presentations. 

Auxiliary meetings

Whether formal or informal, meetings are one of the big values of the conference—relationships are key to everyone’s success, and meeting with attendees in one-on-one environments was incredibly productive. 

Poster session

The poster sessions were excellent. States are really into this event, and it is a great opportunity for the MESC community to engage with the states and see what is going on in the Medicaid Enterprise space.

Wednesday

Some memorable phrases heard in the sessions:

  • Knowledge is power only if you share it
  • We are in this together and want the same outcomes, so let’s share more
  • Two challenges to partnering projects—the two “P”s—are purchasing and personnel
  • Don’t let perfection be the enemy of the good
  • Small steps matter
  • Sharing data is harder than it needs to be—keep in mind the reason for what you are doing

Our evening social event was another great opportunity to connect with the community at MESC and the view of Chicago was beautiful.

Julie Boughn challenged us to set a goal (objective) in the coming year, and, along with it, to target some key results in connection with that goal. Here are some of her conference reflections:

  • Awesome
    • Several State Program and Policy leaders participated at MESC—impressed with Medicaid Director presence and participation
    • Smaller scoped projects are delivering in meeting the desired improved speed of delivery and quality
    • Increased program-technology alignment
  • Not so awesome
    • Pending state-vendor divorces
    • Burden of checklists and State Self-Assessments (SS-As)—will have something to report next year
    • There are still some attempts at very large, multi-year replacement projects—there is going to be a lot of scrutiny on gaining outcomes. Cannot wait five years to change something.

OKRs and request for states and vendors

  • Objective: Improve the quality of services for our users and other stakeholders
    • Key Result (KR): Through test results and audits, all States and CMS can state with precision, the overall accuracy of Medicaid eligibility systems.
    • KR: 100% of State electronic visit verification (EVV) systems are certified and producing annual performance data.
    • KR: 100% of States have used CMS-required testing guidance to produce testing results and evidence for their eligibility systems.
  • Objective: Ensure high-quality data is available to manage the program and improve policy making
    • KR: Transformed Medicaid Statistical Information System (T-MSIS) data is of sufficient quality that it is used to inform at least one key national Medicaid policy decision that all states have implemented.
    • KR:  Eliminate at least two state reporting requirements because T-MSIS data can be used instead.
    • KR: At least five states have used national or regional T-MSIS data to inform their own program oversite and/or policy-making decisions.
  • Objective: Improve how Medicaid technology projects are procured and delivered
    • KR: Draft standard language for outcomes metrics for at least four Medicaid business areas.
    • KR:  Five states make use of the standard NASPO Medicaid procurement.
    • KR:  CMS reviews of RFPs and contracts using NASPO vehicle are completed within 10 business days.
    • KR:  Four states test using small incremental development phases for delivery of services.
  • Request: Within 30 days, states/vendors will identify at least one action to take to help us achieve at least one of the KRs within the next two years.

Last thoughts

There is a lot to digest, and I am energized to carry on. There are many follow-up tasks we all have on our list. Before we know it, we’ll be back at next year’s MESC and can check in on how we are doing with the action we have chosen to help meet CMS’s requirements. See you in Boston!

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MESC 2019―Reflections and Daily Recap

Do we now have the puzzle pieces to build the future?

As I head home from a fabulous week at the 2018 Medicaid Enterprise Systems Conference (MESC), I am reflecting on my biggest takeaways. Do we have the information we need to effectively move into the next 12 months of work in the Medicaid space? My initial reaction is YES!

The content of the sessions, the opportunities to interact with states, vendors, and the Centers for Medicare and Medicaid Systems (CMS) representatives were all rich and rewarding.

The underlying message from Julie Boughn, the CMS Director Data and Systems Group? This is “The Year of Data Quality” and the focus will be migrating to outcomes-based projects. CMS indicated they would like their regional representatives and state agencies to be aware of their top three priorities, focus on those, and be able to exhibit measurable progress in the next year.

Here are three ways states can focus their efforts in "The Year of Quality":

  1. Fix identified areas that have issues (every state has T-MSIS areas they can correct)
  2. Maintain data quality over time, especially through system enhancements
  3. Be aware of CMS plans to use and share T-MSIS data

CMS’ overall goals and vision for improvement include:

  • Creating faster delivery of well-functioning capabilities
  • Improving user experience for all users: produce timely, accurate, and complete data
  • Better monitoring and reporting on business process outcomes

I interpret Julie Boughn’s message and direction to be: keep our efforts realistic, focus on tangible results/outcomes, and realize that CMS is approachable.

While we work on outcomes, there may be some additional changes coming to the certification approach—even beyond the most recent updates from CMS. I think there is general understanding that the work we do in the Medicaid space is iterative, and we will always be improving and changing to adapt to the shifting environment and needs of our beneficiaries, stakeholders, and administration.

As I commuted on Portland’s MAX rail line between my hotel, the conference venue, and other events, I remembered Portland’s 2010 conference (then known as the MMIS Conference) and how the topics covered then and now are evidence of just how much we have evolved.

First, we were the MMIS Conference—now there is a much broader view of the Medicaid arena and our attention is on the Medicaid Enterprise—which includes the MMIS.

Second, in 2010 the nation was coming out of the Great Recession and there was a significant amount of energy spent on implementing initiatives on the American Recovery and Reinvestment Act (ARRA). With it came a host of initiatives: meaningful use, as it related to incentives for providers to utilize electronic health records, states were subsequently updating their Medicaid IT and information exchange plans, and ICD-10 implementation readiness was a hot topic.

Fast forward to 2018, where session topics included modularity, re-use, health outcomes, coordinated care, data quality measures, programs to improve and enhance care, the opioid epidemic, long-term care, care delivery systems, payment, and certification measures. The general focus has migrated to include areas far beyond technology and the MMIS.

As we move into the next 12 months of work in the Medicaid space and look forward to gathering in Chicago for the 2019 MESC, the answer is YES, we have a clear direction and vision for moving forward. And we know things will continue to change in coming years. Are you ready to reassemble the pieces to fit and build the evolving picture of Medicaid?

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MESC 2018 reflections–Portland, Oregon

The MESC “B’more for healthcare innovation” is now behind us. This annual Medicaid conference is a great marker of time, and we remember each by location: St. Louis, Des Moines, Denver, Charleston… and now, Baltimore. The conference is not only a way to take stock of where the Medicaid industry stands. It is a time to connect with the state and vendor community, explore challenges and best-practice solutions, and drive innovation with our respective projects.

Having an opportunity to reflect on MESC over the last several years, I’ve discovered that taking stock of how much has changed (or not) is a valuable exercise. 

Changes at CMS

At the federal level, there is the departure of a long time contributor — Jessica Kahn — who is no longer with CMS. Her contributions and absence were marked in both the opening and closing plenary. We are grateful for her dedication and many contributions to the Medicaid space. In this time of change, we look forward to continuing our work with CMS leadership CMS to advance the mission of Medicaid.

Innovation and Collaboration

Many of the sessions this year were updates on modularity, system integration, and certification, and sessions on expanding or maturing innovative approaches to achieving our triple aim. While there did not seem to be any earth-shattering changes, calls for innovation and collaboration continue. This can be difficult to achieve during a time of anticipated change, but necessary, as states strive to realize improvements in their systems and operations.

Data-Driven Decisions

One of the dominating conference themes was a reiteration of the need to access data from broad sources within and outside Medicaid, and to leverage that data for policy and operation-related solutions and decision-making. Key words like “interoperability” and “sustainability” could be heard echoing through the halls. There is no one-size-fits-all solution on how to break out of stove pipes of data, but some new technologies may be viable tools to meet the challenge. 

Strategic Planning for the Future

States remain focused on refining and following their strategic plans and roadmaps in a time of uncertainty — with regard to potential changes coming from the federal level. The closing plenary suggested that states be prepared for “local leadership” opportunities, which further underscores the need for states to continue to prepare themselves and their systems to facilitate changes to their programs.

Maintaining Perspective

As I leave Baltimore to return home and help care for my 88-year-old father, and as I see others who are in clear need of healthcare help, I am reminded that the work we do and the problems we are tackling are important on so many levels. It is a cornerstone of the well-being of our health system and our fellow citizens. Our team will continue to focus our efforts with this perspective in mind, drawing from the lessons, discussions, and best practices shared at this year’s MESC.

Here’s to a year of good health — may you successfully carry out the mission of Medicaid in your state. See you in 2018 in Portland, Oregon!

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Reflections on MESC 2017

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.

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

Read this if you are in a management role at a state Medicaid agency.

States are facing unique pressure on resources and budgets due to the COVID-19 pandemic, coupled with potential uncertainty following an election year. Healthcare innovation and transformation is one route state Medicaid agencies (SMAs) may take to minimize operational costs and improve access to services. Here are some tactics, flexibilities, and practical steps to help realize innovation during this time.

US Supreme Court Justice Louis Brandeis is credited in 1932 with popularizing the phrase that states are the “laboratories of democracy”. In this case, Medicaid may be the ‘laboratory of health policy and innovation", in part as state Medicaid and Children’s Insurance Programs (CHIP) are collectively the largest US healthcare payer, covering 74 million individuals.

In 2020, states have faced the dual challenge of a public health emergency and corresponding state budget uncertainty, squeezing resources just as projected state revenues have dramatically shrunk. SMAs must be creative to meet competing priorities: administering their programs while responding to the public health emergency. Here are some tactics, flexibilities, and practical steps to help realize innovation during this time. 

Reimagining funding for state Medicaid agencies

Identifying a source of funding is often challenging. Three options to consider include:

  1. Advance Planning Documents (APDs)
    While strictly for information systems, APDs can unlock 90/10 match for Development, Design, and Implementation (DDI) or a 75/25 match for operations. This funding is above most state Federal Medical Assistance Percentages (FMAPs). Realistically, program changes generally require system changes too. Consider reviewing whether you could tie the initiative to Medicaid Information Technology Architecture (MITA) business process maturity and/or outcomes-based system certification criteria. Linking personnel, training, project management, and any equipment for system needs into an APD can be an effective way to help fund the process and system changes.
  2. Partnerships
    An SMA can look further afield if sister agencies have funds available. This is especially true if braiding federal payment streams is an option. For example, many developments that benefit Medicaid can also help CHIP. The federal matching rate for state CHIP programs is typically about 15 percentage points higher than the Medicaid matching rate.  
  3. Certified Public Expenditures (CPE)
    Under 42 CFR § 433.51 and the Social Security Act, another governmental entity besides the SMA can contribute state matches allowing the state to draw Federal Financial Participation (FFP). One option can be another governmental entity using state dollars at the state, county, or even local level, to deliver health services (if covered under the Medicaid state plan) to Medicaid members.  

Interagency cooperation to generate savings in the health and human service (HHS) space will be the topic of a forthcoming article.

Getting help: Communications planning and the role of project management

As SMAs pursue more complex initiatives such as addressing Social Determinants of Health (SDoH)—collaborating not just with providers but with other public agencies, community organizations, vendors, federal partners, advocacy groups, and health systems—the need to coordinate such a diverse circle of stakeholders increases. Demonstration projects, system implementation efforts, and major healthcare initiatives in particular, require coordination of stakeholders throughout each project phase.

Health and human services (HHS) organizations sometimes underestimate the role of project management. For example, project management is often seen as simply “making sure things are complete” by the deadline, but there are other advantages such as establishing efficiency, improving the quality of service delivery, controlling costs, and better coordinating staff for the SMA. With stretched public workforces and more tasks in the current business environment, you want to get as much done—preferably faster, cheaper, and with less risk—and deliver the expected benefits. 

Guidance on priorities from senior leadership can help organizations establish clear and visible sponsorship to help establish success. Strategic change needs a strong champion within the SMA who has the ability to convene key stakeholders and keep projects on task.

Procuring the tools

After determining funding and before executing a project, you prepare by getting the tools you need—whether tools that involve systems, subject matter experts, or general project assistance.  If the Request for Proposal (RFP) process is not an option, consider whether a pre-qualified vendor list or cooperative contract vehicle would work for you. Cooperative contracts are increasingly popular at the federal, state, and local levels. A few cooperative options include:

The solution is strategy

Keeping Medicaid innovation moving forward requires strategic focus that combines funding, communications, project management, and procurement. The strategy you develop can help the outcome of the initiative to be greater than the sum of its parts. By using all available tools, including those discussed here, your SMA can prioritize innovation.

Next steps

  • Evaluate your program and identify initiatives to prioritize in the coming year. Ask your CMS contact about the latest applicable guidance. 
  • Develop APDs to help fund technology needs for initiatives, along with training your SMA team and providers. 
  • Implement a communications management approach to engage stakeholders.
  • Marshal project management resources and develop a realistic and achievable roadmap to success.   
  • Explore agency contracting vehicles, cooperative contracts, and other procurements tools. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team
 

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The solution to help Medicaid innovation moving forward

CYSHCN programs have new care coordination standards―how does your agency measure up?

On October 15, 2020, the National Academy for State Health Policy (NASHP) released new care coordination standards for Children and Youth with Special Health Care Needs (CYSHCN) programs. The National Care Coordination Standards supplement the National Standards for Systems of Care, helping to ensure that children and youth with special health care needs receive the high-quality care coordination needed to address their specific health conditions.

The standards also set requirements for screening, identification, and assessment, a comprehensive shared plan of care, coordinated team-based communication, development of child and family empowerment skills, a well-trained care coordination workforce, and smooth care transitions. 

What do the standards mean for CYSHCN programs

The National Care Coordination Standards are more than guidelines for CYSHCN programs; aligning with the standards can lead to operational efficiencies, greater program capacity, and improved health outcomes. The standards can serve as a lens for continuous improvement, highlighting where programs can make changes that reduce the burden on care coordinators and program administrators.

However, striving to meet the standards can be challenging for many programs—as the standards develop and evolve over time, many programs struggle to keep up with the work required to update processes and retrain staff. Assessing a CYSHCN program’s processes and procedures takes time and resources that many state agencies do not have available. Despite the challenge, when state agencies are the most strapped is often when making change is the most needed. A shrinking public health workforce and growing population of CYSHCN means smooth processes are essential. To take steps towards National Care Coordination Standards alignment, BerryDunn recommends the following approach: 

A proven methodology for national standards alignment

There are many ways you can align with the standards. Here are three areas to focus on that can help you guide your agency to successful alignment. 

  1. Know your program
    It can be easy for processes to deteriorate over time. Process mapping is an effective way to shed light on current work flows and begin to determine holes in the processes. Conducting fact-finding sessions to map out exactly how your program functions can help pinpoint areas of strength―and areas where there is room for improvement.
  2. Compare to the national standards
    Identify the gaps with a cross-walk of your program’s current procedures with the National Care Coordination Standards. We assess your alignment through a gap analysis of the process, highlighting how your program lines up with the new standards.
  3. Adopt the changes and reap the benefits
    Process redesign can help implement the standards, and even small adjustments to processes can lead to better outcomes. Additionally, you can deploy proven change management methodologies programs that ease staff into new processes to produce real results.

Meeting national standards doesn’t have to be complicated. Our team partners with state public health agencies, helping to meet best practices without adding additional burden to program staff. We can help you take the moving pieces and complex tasks and funnel them into a streamlined process that gives your state’s children and youth the best care coordination. 

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Using process redesign to align with new CYSHCN standards

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.

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