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Three steps to
outcomes-based
certification

12.04.19

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.

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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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.

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.

Article
Three steps to measure Medicaid Enterprise Systems outcomes

Read this if you are at a state Medicaid agency.

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

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

What’s next?

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

Waivers

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

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

Funding

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

State considerations

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

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

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

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

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

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

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

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

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

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

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

Article
Coordinating initiatives across state HHS: Questions to ask

Read this if you are a division of motor vehicles, or interested in mDLs.

What is a mobile driver’s license?

A mobile driver’s license (mDL) is a solution that allows citizens to access, update, and use their driver’s license via a smart phone or other internet-accessible device (e.g., laptop, tablet, smart watch). An mDL is a form of electronic identification (eID), but where eIDs include other forms of licensure like hunting/fishing/gaming licenses or military IDs, mDLs are used to designate driving privileges and, in some cases, to designate age-based/identity privileges for citizens who cannot drive (e.g., buying alcohol, TSA PreCheck®).

Why should you care?

Technology has replaced physical product functionality within various areas of modern life. Many people have transitioned to electronic credit/debit card payments (e.g., Apple Pay), making paying for everyday items faster, easier, and cleaner, while also introducing risks to consumer data security. Similar functionality will soon exist within the eID space, starting with mDLs. This provides challenges for departments of motor vehicles (DMVs), businesses, and consumers; however, the benefits of adopting mDL functionality outweigh the growing pains of establishing the programs.

How does it work and when will it be implemented?

The mDL will function similarly to electronic credit cards and mobile payment applications: an mDL user loads their mDL to their mobile device using a mobile application and can use it to verify their age and driving credentials at mDL-reading establishments and with law enforcement. Relevant establishments will require both hardware and software solutions to read mDLs. 

mDLs aren’t intended to replace physical licenses—at least not yet. While state and county pilot programs resolve some of the challenges associated with mDLs, physical IDs will remain required for years to come. 

Additionally, the American Association of Motor Vehicle Administrators (AAMVA) created two groups—a Card Design Standard Committee and Electronic Identification Working Group—to develop interoperable standards to assist license issuing authorities (e.g., DMVs) in developing their mDL programs. These standards will ensure that mDLs work using different hardware, software, vendor applications, and within different jurisdictions. 

Benefits and challenges

Benefits

mDLs provide numerous benefits to citizens and DMVs alike, including information security, user convenience, and administrative convenience.

Information security

  • mDLs are harder to fake than physical driver’s licenses due to the mDL’s connection to back-end license data within the DMV system. 

  • mDLs allow users the option to communicate specific data to the receiving party without sharing all of the user’s license information (e.g., confirming the user is over age 21 without sharing their specific age or street address). 

User convenience

  • Users will be able to update their credentials fully online and see in-real-time updates.
  • mDLs will possess single sign-on verification and use for users via a biometric lock or PIN, making them quick to access and easy to use.

Administrative convenience

  • The decline in DMV wait times due to online-update functionality will save DMVs money in administrative costs.

Challenges

As with all technological advancement, there are several challenges around the development of mDLs. The primary challenge is ensuring the protection of user data while also rolling out the complex—and often costly—infrastructure needed to support mDL use across a region. 

Information security 

  • Issuing agencies can choose whether some, none, or all mDL user data is stored on the user’s device and must ensure all data stored this way is done so securely.

  • mDLs must ensure hands-free exchange of information with law enforcement to protect user data when presenting identification.

  • Technological errors are bound to occur: if an mDL-reading establishment is not able to read a citizen's mDL for any reason, a citizen will require a physical license to complete the transaction.

Program rollout

  • States and mDL vendors will need to support interoperable mDL standards to ensure that an mDL works with different vendor software and across jurisdictions.

  • Establishments and law enforcement will need the necessary mDL-reading hardware (smart phone, smart watch, tablet, laptop, point-of-sale terminal) and software (QR code readers, Bluetooth functionality, Wi-Fi Aware, Nearfield Communication, etc.) to read mDLs.

  • mDLs must be able to function in both offline and online scenarios to ensure the security of consumer data and proper functionality.

The future

mDLs are just the beginning of the opportunities eID technology will bring. Once established by DMVs, eID technology can and will be used to find and buy insurance services, check medical prescriptions, apply for social/welfare benefits, open hunting/fishing/gaming accounts and display appropriate credentials, and access pension information. 

The versatility that eID technology provides will streamline American citizens’ identification arsenal, and the advancing mDL technology puts us on the path to get there. The question is not will mDLs become widespread, but when.
 

Article
Introduction to mobile driver's licenses (mDLs): What are they and why are they important?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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