State Medicaid programs have evolved tremendously since the implementation of the Affordable Care Act (ACA). Their evolution will continue as the Centers for Medicare & Medicaid Services (CMS) works to improve on a program that has grown extensively and is still working to meet the overarching goals of the ACA. From CMS' Notice of Proposed Rule Making (NPRM) for Medicaid programs that use a managed care model, which proposed new guidelines for modernization, to President Obama's January announcement that the Federal government will offer financial incentives for states that expand their coverage, Medicaid programs are looking to meet these new requirements, all while trying to extend their resources and modernize their programs to best meet the needs of their beneficiaries.
One of the biggest challenges that state Medicaid programs face in meeting the ACA's requirements is the breadth of their health plan provider networks. Following the passage of the law, states began to see the rise of "shallow networks," which are managed care health plans that have a limited number of physicians available in their network. Some of this is driven by an effort to keep premium costs low and some is the difficulty in establishing a financially-viable practice for physicians, especially in rural areas. Whatever the reason, many beneficiaries have been experiencing limited access to physicians and specialists, which makes simple tasks such as getting an appointment in a reasonable amount of time a challenge. It also puts the goal of improving patient care and outcomes in jeopardy.
To remediate this, state Medicaid Directors must seek new solutions to assess the provider networks within these health plans and ensure that the screening, enrollment and ongoing oversight of these provider relationships is appropriately managed to ensure access for beneficiaries. Three key areas will be critical to the success of that endeavor:
#1: Maintain Data Integrity
The success of a state's provider screening and enrollment project will be heavily dependent on the accurate and timely exchange of data between the provider data management system (PDMS) and the existing state systems. The state's PDMS should use a flexible data model that allows for automated feeds of information to cross-reference and ensure the integrity of provider data. These interfaces must present information in real-time (or at least daily updates) between systems in order to ensure the data being accessed is accurate. MAXIMUS works with multiple states, forming new ideas for how provider data should be structured and made available outside of the traditional Medicaid Management Information System (MMIS), with the goal of avoiding built-in constraints that impact data sharing and advanced business processes. In Tennessee, we are using these concepts to design, develop and implement technology systems that support the State's Medicaid providers that enables provider management capabilities separate from the MMIS.
#2: Improve Effectiveness and Agility
To improve effectiveness and agility provider networks, states should look to increase how they support the expansion of managed care populations and help facilitate the modernization of the Medicaid program. Utilizing tools that leverage self-service functionalities, like a provider portal, electronic document submission and payment options, can help reduce redundancies and improve overall efficiency by enabling the providers to perform tasks on their own and at their pace. In our Tennessee project, our self-service registration portal is currently the source of all provider applications, and has been instrumental in streamlining operations in a number of other state's provider projects. Of course, the ideal solution for any state should be able to be deployed quickly and be adaptable to changing requirements, including future health care mandates and state initiatives, to increase beneficiary enrollment in managed care.
#3: Implement Personalized Technology
As with most technology solutions, a "one-size-fits-all" approach is rarely the answer. Ultimately, each state will need a solution that is flexible and allows it to tailor the optimal balance of technology and services to fit both policy objectives and operational preferences. Medicaid Directors must seek solutions that decouple provider management from the limitations of older technologies, such as the MMIS, since those will create the greatest opportunity for building functional solutions around the needs and expectations of medical providers and state workers. In Nebraska, we have been tasked with supporting the new ACA compliance requirements for provider enrollment and screening, enabling technology and services for the State to expedite the application process, performing risk screening of high and medium risk providers and conducting site visits to validate the provider. While we are employing a Nebraska-specific approach for them, each state should ensure that their solution addresses their own unique requirements.
Medicaid Directors across the U.S. are very focused on developing strategies to ensure their beneficiaries have appropriate provider network access, and if Health and Human Services Secretary Sylvia Burwell's prediction that Medicaid expansion will be embraced by more states is correct, it is no longer an issue of "if," but "when." By focusing on these three areas, states can begin to satisfy the rigorous requirements of shifting their beneficiaries to managed care health plans, while ensuring that they have readily-available access to health care professionals.