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Three steps to measure Medicaid Enterprise Systems outcomes

By: Christopher Davis,

Jodie is a Senior Consultant in BerryDunn’s Government Consulting Group serving on the Independent Verification and Validation (IV&V) Services team for Missouri Department of Social Services, Missouri Eligibility Determination and Enrollment System (MEDES) project. She and the team assess project health, identify potential risks and issues, and offer recommendations for mitigation. She is a Project Management Professional (PMP)® and Prosci® certified change practitioner (CCP) with over 20 years of hands-on project experience, and is proficient in systems analysis, implementation oversight, and federal standards compliance.

Jodie Earney
08.19.19

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

Measuring performance of Medicaid Enterprise Systems (MES) is emerging as the next logical step in moving Medicaid programs toward modularity. As CMS continues to refine and implement outcomes-based modular certification, it is critical that states adapt to this next step in order to continue to meet CMS funding requirements.

This measurement, in terms of program outcomes, presents a unique set of challenges, many of which a state may not have considered before. A significant challenge is determining how and where to begin measuring program outcomes―to meet it, states can leverage a trusted, independent partner as they undertake an outcomes-based effort.

Outcomes-based planning can be thought of as a three-step process. First, and perhaps most fundamental, is to define outcomes. Second, you need to determine what measurements will demonstrate progress toward achieving those outcomes. And the final step is to create reporting measurements and their frequency. Your independent partner can help you answer these critical questions and meet CMS requirements efficiently by objectively guiding you toward realizing your goals.

  1. Defining Outcomes
    When defining an outcome, it is important to understand what it is and what it isn’t. An outcome is a benefit or added value to the Medicaid program. It is not an output, which is a new or enhanced function of a new MES module. An output is the product that supports the outcome. For example, the functionality of a new Program Integrity (PI) module represents an output. The outcome of the new PI module could be that the Medicaid program continuously improves based on data available because of the new PI module. Some outcomes may be intuitive or obvious. Others may not be as easy to articulate. Regardless, you need to direct the focus of your state and solution vendor teams on the outcome to uncover what the underlying goal of your Medicaid program is.
     
  2. Determining Measurements
    The second step is to measure progress. Well-defined Key Performance Indicators (KPIs) will accurately capture progress toward these newly defined outcomes. Your independent partner can play a key role by posing questions to help ensure the measurements you consider align with CMS’ goals and objectives. Additionally, they can validate the quality of the data to ensure accuracy of all measurements, again helping to meet CMS requirements.
     
  3. Reporting Measurements
    Finally, your state must decide how―and how often―to report on outcomes-based measurements. Your independent partner can collaborate with both your state and CMS by facilitating conversations to determine how you should report, based on a Medicaid program’s nuances and CMS’ goals. This can help ensure the measurements (and support information) you present to CMS are useful and reliable, giving you the best chance for attaining modular certification.

Are you considering an outcomes-based CMS modular certification, or do you have questions about how to best leverage an independent partner to succeed with your outcomes-based modular certification effort? BerryDunn’s extensive experience as an independent IV&V and Project Management Office (PMO) partner includes the first pilot outcomes-based certification effort with CMS. Please visit our IV&V and certification experts at our booth at MESC 2019 or contact our team now.

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

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

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

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

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

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

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

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

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

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

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

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

Article
Outcomes and organization development, part II

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

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


What is organization development (OD)? 

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

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

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

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

What is the scope of an OD effort? 

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

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

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

What does OD look like in action? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You can learn more in Part II of our Outcomes and Organization Development podcast and article

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

Article
Outcomes and organization development 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Article
Outcomes and APD considerations

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

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


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

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

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

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

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

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

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

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

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

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

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

Article
Scaling project outcomes

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

You can listen to the companion podcast to this article now:


Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline Medicaid Enterprise System (MES) certification. During this time, we have been fortunate enough to have been a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. 

What is outcomes-based certification (OBC)? 

OBC (or streamlined modular certification) is a fascinating evolution in MES certification. OBC represents a fundamental rethinking of certification and how we measure the success of system implementation and modernization efforts. The prior certification approach, as many know it, is centrally focused on technical capability, answering the question, “Can the system perform the required functions?” 

OBC represents a shift away from this technical certification and toward business process improvement, instead answering the question, “How is this new technology enhancing the Medicaid program?” Or, put differently, “Is this new technology helping my Medicaid program achieve its desired outcomes?” 

What are the key differences between the MECT and OBC? 

To understand the differences, we have to first talk about what isn’t changing. Technical criteria still exist, but only so far as CMS is confirming compliance with core regulatory and statutory requirements—including CMS’ Standards and Conditions. That’s about the extent of the similarities. In addition to pivoting to business process improvement, we understand that CMS is looking to generalize certification under this new approach, meaning that we wouldn’t see the same Medicaid Information Technology Architecture (MITA)-tied checklists like Provider Management, or Decision Support Systems. Instead, we might expect more generalized guidance that would allow for a more tailored certification. 

Additionally, OBC introduces outcomes statements which serve as the guiding principles for certification. Everything, including the technical criteria, roll-up into an outcome statement. This type of roll up might actually feel familiar, as we see a similar structure in how Medicaid Enterprise Certification Toolkit (MECT) criteria rolled up into critical success factors. 

The biggest difference, and the one states need to understand above all else, is the use of key performance indicators (KPIs). These KPIs aren’t just point-in-time certification measures, they are expected to be reported against regularly—say, quarterly—in order to maintain enhanced funding. Additionally, it’s likely that each criterion will have an associated KPI, meaning that states will continue to be accountable to these criteria long after the Certification Final Review. 

How are KPIs developed? 

We’ve seen KPIs developed in two ways. For more strategic, high level KPIs, CMS develops a baseline set of KPIs heading into collaborating with a state on an OBC effort. In these instances, CMS has historically sought input on whether those KPIs are reasonable and can be easily reported against. CMS articulates what it wants to measure conceptually, and works with a state to ensure that the KPI achieves that within the scope of a state’s program.  

For KPIs specific to a state’s Medicaid program, CMS engages with states to draft new KPIs. In these instances, we’ve seen CMS partner with states to understand the business need for the new system, how it fits into the Medicaid enterprise, and what the desired outcome of the particular approach is. 

What should states consider as they plan for MES procurements? 

While there might be many considerations pertaining to OBC and procurements, two are integral to success. First—as CMS noted in the virtual MESC session earlier this month—engage CMS at the idea stage of a project. Experience tells us that CMS is ready and willing to collaborate with—and incorporate the needs of—states that engage at this idea stage. That early collaboration will help shape the certification path. 

Second, consider program outcomes when conceptualizing the procurement. Keep these outcomes central to base procurement language, requirements, and service level agreements. We’re likely to see the need for states to incorporate these outcomes into contracts. 

What does this mean for MES modularity and scalability? 

Based on our current understanding of the generalization of certification, states, and subsequently the industry at large, will continue to refine what modularity means based on Medicaid program needs. Scalability represents an interesting question, as we’ve seen OBC scaled horizontally across smaller, discrete business areas like pharmacy or provider management. Now we’re seeing the beginnings of vertical scaling of a more streamlined certification approach to larger components of the enterprise, such as financial management and claims processing. 

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

Article
Considerations for outcomes-based certification

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

On October 24, 2019, the Centers for Medicaid and Medicare Services (CMS) published the Outcomes-Based Certification (OBC) guidance for the Electronic Visit Verification (EVV) module. Now, CMS is looking to bring the OBC process to the rest of the Medicaid Enterprise. 

The shift from a technical-focused certification to a business outcome-focused approach presents a unique opportunity for states as they begin re-procuring—and certifying—their Medicaid Enterprise Systems (MES).

Once you have defined the scope of your MES project—and know you need to undertake CMS certification—you need to ask “what’s next?” OBC can be a more efficient certification process to secure Federal Financial Participation (FFP).

What does OBC certification entail?

Rethinking certification in terms of business outcomes will require agencies to engage business and operations units at the earliest possible point of the project development process to define the program goals and define what a successful implementation is. One way to achieve this is to consider MES projects in three steps. 

Three steps to OBC evaluation

Step 1: Define outcomes

The first step in OBC planning seems easy enough: define outcomes. But what is an outcome? To answer that, it’s important to understand what an outcome isn’t. An outcome isn’t an activity. Instead, an outcome is the result of the activity. For example, the activity could be procuring an EVV solution. In this instance, an outcome could be that the state has increased the ability to detect fraud, waste, and abuse through increased visibility into the EVV solution.

Step 2: Determine measurements

The second step in the OBC process is to determine what to measure and how exactly you will measure it. Deciding what metrics will accurately capture progress toward the new outcomes may be intuitive and therefore easy to define. For example, a measure might simply be that each visit is captured within the EVV solution.

Increasing the ability to detect fraud, waste, and abuse could simply be measured by the number of cases referred to a Medicaid fraud unit or dollars recovered. However, you may not be able to easily measure that in the short-term. Instead, you may need to determine its measurement in terms of an intermediate goal, like increasing the number of claims checked against new data as a result of the new EVV solution. By increasing the number of checked claims, states can ensure that claims are not being paid for unverified visits. 

Step 3: Frequency and reporting

Finally, the state will need to determine how often to report to measure success. States will need to consider the nuances of their own Medicaid programs and how those nuances fit into CMS’ expectations, including what data is available at what intervals.

OBC represents a fundamental change to the certification process, but it’s important to highlight that OBC isn’t completely unfamiliar territory. There is likely to be some carry-over from the certification process as described in the Medicaid Enterprise Certification Toolkit (MECT) version 2.3. The current Medicaid Enterprise Certification (MEC) checklists serve as the foundation for a more abbreviated set of criteria. New evaluation criteria will look and feel like the criteria of old but are likely to be a fraction of the 741 criteria present in the MECT version 2.3.

OBC offers several benefits to states as you navigate federal certification requirements:

  1. You will experience a reduction in the amount of time, effort, and resources necessary to undertake the certification process. 
  2. OBC refocuses procurement in terms of enhancements to the program, not in new functions. Consequently, states will also be able to demonstrate the benefits that each module brings to the program which can be integral to stakeholder support of each module. 
  3. Early adoption of the OBC process can allow you to play a more proactive role in certification efforts.

Continue to check back for a series of our project case studies. Additionally, if you are considering an OBC effort and have questions, please contact our team. You can read the OBC guidance on the CMS website here
 

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Three steps to outcomes-based certification

Read this if you are at a state agency looking to implement or improve your 988 Suicide & Crisis Lifeline. 

Between 2015 and 2020, one in four fatal police shootings involved a person with a mental illness, and an estimated 44% of people incarcerated in jail and 37% of people incarcerated in prison had a mental health condition. In addition, the recent COVID-19 pandemic has adversely impacted the mental health situation in the country. 

Many people experiencing mental health distress call 911 because it is a widely known emergency number and easy to use. Recent data has shown that people using 911 to get help with serious mental illness do not get the right care at the right time and some even end up in law enforcement custody, rather than being seen by a mental health professional.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) is the new three-digit, nationwide phone number that is locally operated and offers 24/7 access via call, text, and chat to trained crisis counselors who can help individuals experiencing mental health-related distress. Mental health-related distress can include substance use crisis, suicidal thoughts, depression, or any emotional distress. The 988 Suicide & Crisis Lifeline is also available for individuals worried about a loved one who might need crisis support services. Its goal is to provide accessible and immediate crisis intervention and support to every individual in need. 

988 state implementation and top challenges

As of August 2022, 23 states have passed legislation to facilitate the implementation of the 988 Suicide & Crisis Lifeline. Colorado, Nevada, and Washington enacted legislation with user fees to support 988 operations and provide financial sustainability for the system. Several states have established advisory groups or planning committees with representatives from state agencies, health providers, law enforcement, emergency medical services, and other partners to better coordinate the system and identify policy levers. 

Implementing a three-digit number for behavioral health emergencies in every state and providing 24/7 primary coverage through in-state call centers have presented certain challenges to states across the nation. As states prepare to launch the 988 hotlines, they have encountered key issues around infrastructure, workforce, 911 integration, readiness of the crisis care continuum, cultural competence, and performance management.  

Solutions for state agencies

To address these key issues, states should consider the following to aid in the successful implementation of the 988 Suicide & Crisis Lifeline:

Assess the states’ needs to successfully implement the 988 Suicide & Crisis Lifeline

Despite meeting baseline requirements for the implementation of the 988 Suicide & Crisis Lifeline, state agencies are struggling to implement the 988 Suicide & Crisis Lifeline. 

By performing a structured needs assessment, state agencies can evaluate their infrastructure, policies and procedures, funding, and workforce needs to better understand their readiness to implement and capability to sustain the 988 Suicide & Crisis Lifeline. This assessment provides insight for state agencies to understand their strengths, challenges, and areas of opportunity, and it should evaluate: 

  • State infrastructure
    Behavioral health leaders acknowledge that infrastructure supports are necessary to make the 988 Suicide & Crisis Lifeline work across the continuum of care. It is important to assess the infrastructure across the crisis care continuum to help ensure a smooth transition for individuals who need care quickly. Successful implementation should take certain considerations into account during the planning process, such as including all the interested parties representing diverse populations.
  • Workforce
    In the current labor market, workforce availability and retention are top concerns for sustainable and effective 988 Suicide & Crisis Lifeline operations. States are struggling to hire the extra staff needed to launch the 988 Suicide & Crisis Lifeline as well as to recruit qualified persons. To realistically implement the system, innovative workforce development and supporting wages to recruit and retain a specialized workforce are critical considerations for the states. Critical components to include in the assessment should include, but are not limited to:
    • Training
      Staff training and proper supervision will be crucial to effectively manage the 988 Suicide & Crisis Lifeline, and states need best practices models for how to best train crisis responders and the call center staff. States should assess the existing training infrastructure to identify ways early on to support the mental health of their 988 Suicide & Crisis Lifeline counselors to reduce the risk for burnout and post-traumatic stress disorder. 
    • Capacity
      Adequate capacity is a key factor to workforce. The assessment should identify the number of qualified workforce available for in-person staffing. In the current labor market, it will also be important to consider including the identification of the number of qualified staff able to work remotely. If states would like to consider remote capabilities for the call centers, it will also be important to assess the available technology necessary, as well as the development of standards and expectations, including strong communication. 
  • Readiness of the crisis care continuum
    Apprehension about the readiness of the crisis care continuum (e.g., mobile crisis teams through diversion services and lower levels of care) exist. Federal officials have stated they expect up to 12 million calls/texts/chats in the first year of the 988 Suicide & Crisis Lifeline, and research suggests approximately 20% of those calls/texts/chats will require some level of in-person response. States are questioning whether mobile crisis teams are prepared for the increased demand while also identifying connections and access to upstream services. In addition, states can consider the needs and experiences of the system’s end users to help address equity. The assessment can help to assess the readiness of the various components across the crisis care continuum.

Establish a strategic plan of action to implement the 988 Suicide & Crisis Lifeline 

With the implementation of the 988 Suicide & Crisis Lifeline, state agencies have an opportunity to strengthen crisis care. The best way to begin strengthening crisis care is to develop and implement strategic plans that optimize the 988 Suicide & Crisis Lifeline and the following services. Building on the strengths and opportunities identified in the needs assessment and the associated recommendations, strategic plans can establish priorities and identify sustainable solutions that build capacity, promote equitable access to care, and promote continuous quality improvement. Collaborating with key stakeholders to develop a strategic plan can help identify a roadmap for how the state should approach the implementation, maintenance, and sustainability of the 988 Suicide & Crisis Lifeline, including, but not limited to, the following areas:

  • Data and performance management
  • Stakeholder engagement
  • Health equity
  • Voice of the customer
  • Financial sustainability

Maximize available funding streams

Historically, behavioral health has not had sufficient funding to adequately address mental health and substance use disorder prevention, treatment, and recovery services across the continuum of care. The COVID-19 pandemic exacerbated behavioral health challenges for many individuals struggling and highlighted the challenges with the infrastructure and workforce. In the last couple of years, the federal administration has continued to allocate additional funding to supplement existing and ongoing federal funding. States should begin by evaluating the existing federal funding opportunities to support the implementation of the 988 Suicide & Crisis Lifeline. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 988 Convening Playbook for States, Territories, and Tribes, below are a few examples of funding sources that can be leveraged for the implementation of the 988 Suicide & Crisis Lifeline. 

  • SAMHSA 
    • Transformation Transfer Initiative
    • Community Mental Health Services Block Grant
    • Substance Abuse and Treatment Block Grant
    • Mental Health Block Grant Set-aside
    • State Opioid Response Grant
    • Tribal Opioid Response Grants
  • American Rescue Plan Act (ARPA) of 2021—for Mobile Crisis and Crisis Line Services
  • Medicaid
    • Early, Periodic, Screening, Diagnosis, and Treatment (known as EPSDT)
    • 1915(a) waivers
    • 1915(b) waivers
    • 1115 SMI/SED Service Delivery Waiver

The implementation of the 988 Suicide & Crisis Lifeline is critical to supporting the community and meeting their needs at a time where they need community support the most. If you have any questions, please contact BerryDunn’s behavioral health consulting team. We’re here to help.

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Components of successful implementation of the 988 Suicide & Crisis Lifeline

Read this if you are at a state Medicaid agency.

The uncertainty surrounding the end date of the COVID-19 Public Health Emergency (PHE) has made it difficult for state Medicaid agencies to plan and prepare to transition to pre-pandemic operations. Upon the federal declaration of the PHE, states and territories were forced to react quickly to reduce the impact on the Medicaid program and its enrollees. Many states and territories took advantage of the emergency authorities through the Centers for Medicare and Medicaid Services (CMS) to implement temporary policy changes such as the removal of prior authorization requirements, increased payments to providers, removal of cost-sharing, and the expansion of telehealth services. 

While many of the emergency authorities will terminate on or around the end of the PHE, states and territories may elect to make those temporary changes permanent due to the positive impact for both enrollees and providers. Take telehealth, for example. The broad flexibilities allowed during the PHE permitted providers to meet the healthcare needs of enrollees in a time where in-person visits were not recommended, nor available. To increase access to testing and vaccinations in pharmacies, pharmacy technicians and interns were permitted to administer COVID-19 vaccinations when supervised by an immunizing pharmacist.

So what comes next for states and territories once the PHE ends? Taking a proactive approach to plan out next steps will assist states and territories to be better prepared upon conclusion of the PHE. The US Department of Health and Human Services (HHS) has committed to providing at least a 60-day notice prior to the official end date of the PHE. CMS encourages states and territories to communicate changes to enrollees, managed care plans, counties, providers, and other stakeholders.

As we await the declared end date of the PHE or notification of another extension, states and territories can begin taking actions to prepare for the resumption of normal operations. We have learned new ways to prevent disruptions in meeting the needs of enrollees, developed enhanced methods of communication to stay in touch, and used technology to its fullest capacity. While our new normal is very different than pre-pandemic times, we can all use what we have learned to strengthen our tactics for any future PHEs. BerryDunn is here to assist and support states and territories as they prepare for the eventual end of the PHE.

If you have questions or would like to discuss further, please contact the Medicaid consulting team. We're here to help. You can also read more BerryDunn articles on the PHE unwinding here.

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Looking beyond the Public Health Emergency: What's next for states

Read this if you are a Medicaid agency or attended MESC 2022.

As I depart Charlotte and fly home and MESC 2022 closes out, I understand why Charlotte is referenced as the Queen City. The people make it so, as we were welcomed with open arms in this beautiful place. Our appreciation and gratitude go out not only to Charlotte, but also to NESCSO for providing us with a place to meet, share ideas, get inspired, and deepen our relationships.

In the coming months, our team can sift through what we learned during our four days at MESC. It will be up to us to transform the ideas spawned from presentations and conversations into tangible action, and grow the new relationships we developed. Here are my key takeaways and themes from the conference that I will continue to ponder:

  • The conference is in full swing on the other side of the pandemic. MESC was sold out, as 1,700 people attended.
    • MESC established a new annual award for collaboration. This year the award went to the Public Sector Technology Group's (PSTG) Medicaid Information Technology Architecture (MITA) workgroup. CMS is optimistic that the MITA workgroup's efforts will help improve Medicaid and that the resulting toolkit will be the future of MITA. Thank you to this group, and congratulations on a well-deserved award!
  • Modernization efforts:
    • The reality of managing modernization efforts is settling in. States and territories are beginning to get clear on their approach, acknowledging that each has unique needs, and consequently, can customize their approach. It will be a long haul requiring good upfront strategizing, planning and execution.
    • Many states and territories recognize a need to examine and adjust their internal structures to manage multiple procurements and strategies.
    • Data and data governance is foundational to the modularization and modernization effort.
  • Unwinding is weighing on everyone's mind, but participants discussed other forward-looking topics. 
  • CMS continues to solicit input from states, territories, and vendors
    • This was CMS' first in-person conference since the pandemic's start—it was so great to have their energy and participation.
    • It was fantastic to be in sessions where CMS asked: How can they do better? 
    • Efforts on outcomes, streamlining certification, consistency, and accountability continue to be CMS themes
    • Brent Weaver, CMS' new Data and Systems Group Director, outlined four of CMS' goals at MESC:
      • Strengthen state and territory partnerships
      • Get input from vendors on unwinding
      • Identify ways to improve data quality
      • Find ways that will help CMS become better partners
  • Ensuring health equity and leveraging social determinants for health is a priority for states and territories.
  • New solution vendors are coming into the Medicaid space, and want to learn about Medicaid and the broader enterprise as they look for ways to adapt their systems.  
  • There continues to be mergers and re-shuffling of the more established vendors as they look to adapt to and serve the needs in the Medicaid space.
    • This was BerryDunn's 17th conference. We have broadened our services and maintained our values. I'm grateful that BerryDunn continues to have a stable presence at the conference.  
  • Our Medicaid Practice Group mission statement (see below) aligns with the CMS Data and Systems Group Director's reason for being in his role. 

Additional thoughts: Asking "why," change, and education

I also appreciated conversations within our Medicaid community based on the “why": Why are we doing what we do? Why focus on modernization? Health equity? Social determinants of health? 
The "why" drives what we do by providing us with our North Star, helping us with strategy, and giving us our roadmaps for proceeding. By starting with the purpose and outcome we strive for, we can align the changes we need to make.  

Change can be a source of fear, and there is a risk of venturing into the unknown. Medicaid leaders understand that the work they are responsible for is critical to their members, providers, and taxpayers. Lives depend upon our work, and the potential of "change" can have positive or negative consequences. Effective planning can mitigate the risks and help alleviate staff, member, and provider fears about change. 

Education also plays a big part in the mitigation equation. After tying the purpose to the vision, roadmap, and phased plans to modernize our programs, there needs to be an education plan to bring everyone up to speed and build confidence in those who will be impacted.

Conclusion

I am grateful that the BerryDunn Medicaid Practice Group's mission complements the goals of CMS and the direction in which states and territories are moving. We are honored to participate in this vital work and join all in the Medicaid community as we work on the initiatives before us. I leave you with our mission statement and invite you to share your organization's mission with us.

BerryDunn's Medicaid Practice Group helps Medicaid agencies improve the health and lives of individuals by empowering, inspiring, and partnering with our clients—we innovate, share deep expertise, and provide an independent perspective to resolve challenges. We are the success partner for Medicaid agencies, building healthier communities and stronger futures.

I look forward to seeing you all again next time in Denver! Let's make it a great year!

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MESC 2022: Reflections from 30,000 feet