Modernizing the Medicaid Experience - Streamlining Provider Management

All right, TGIF everyone, and welcome back to another episode of In Case You Missed It. I'm Dustin Haisler, Chief Innovation Officer for Government Technology Magazine. Joe's out today, but we will be returning next week. Today we're going to be talking about modernizing the Medicaid experience, specifically through streamlining provider management. Now, modernization is one of the top topics that we hear, especially at the state level. There's increased pressure and expectation from business stakeholders that expect a modern experience, employees that demand a modern experience. So we're gonna dig into what that means as we look at provider management and really streamlining that process. And we brought in 2 experts to help us break it down, and I'm gonna introduce them and then we'll dig in. First up, we've got John Campbell, the Senior Product Manager, Provider Solutions for Optum State Government Solutions, and Stacia Castro, Solutions Architect for Optum State Government Solutions as well. John and Stacia, thanks so much for carving time out to join me today to dig into this topic.

Pleasure to be here, Dustin.

All right, so let's just start with a little bit about your backgrounds. And Stacia, I'll start with you on this one. Tell us a little bit about your background and your role at Optum.

Sure, definitely. As you shared, I'm a business solution architect currently. Prior to this position, I was a business lead for one of our Medicaid customers, where I ran provider enrollment and provider services, a call center. And then prior to coming to Optum, I have 20 years of government experience with the Medicaid state office and state courts, where I focused on procurement, human services, and policy.

Fantastic. John, how about you? How— tell us a little bit about your role at Optum and your journey there.

Right, so my role with Optum is a product director of product management, and I help to assess products that are coming onto the marketplace or are on the marketplace for applicability to the state government market. And in doing so, I'm also helping to bring some of those products to the market and develop go-to-market plans with them. Prior to joining Optum, I spent a number of years with the state of Utah as an IT director running their legacy MMIS system. And before that, a variety of different industries, including pharmaceuticals and finance, in a variety of technical roles.

Fantastic. Let's kind of dig into this because I know, you know, one of the first things that we see is just that everything around the experience in government has changed in response to the pandemic. A lot of things have kind of reshuffled over the last few years. So, John, I want to start with you. What is that typical Medicaid procurement experience today, and how, if at all, has that changed maybe over the last 24 months?

Well, I think you primed me pretty well there. COVID is the issue, and over the past 24 months, we've been dealing with this pandemic that nobody saw coming. So I think it's fair to say that prior to that, states were proceeding along a trajectory and a path towards modernization of their systems. systems. They had spent a lot of time and effort putting together modernization plans and prioritizing how they wanted to go about doing that. And then March of 2020 happened, and all of those plans got shelved, and states went into reaction mode relative to responding to the crisis. So during that time, though, I think states also had an opportunity to reassess their priorities and take a step back and look at how their systems and capabilities responded to COVID, and that helped them reprioritize some of the systems that they needed to procure sooner rather than later. And in doing so, that's helped to highlight migrations from an on-prem solution to cloud-based opportunities as well because the cloud has continued to evolve in the past 24 to 36 months in good ways. So states are now able to say, well, we were going to go on-prem, let's reassess that and look at a cloud-based strategy. Another thing that's, that's come to fruition has been the NASPO procurement strategy that many states are pursuing, and we're seeing them look at NASPO as a vehicle to get a procurement in the door and work on that in a way that's more expeditious than the traditional procurement model where they would have to issue a full RFP and go through that cycle. So NASPO is a great tool for accelerating that process. But it is also a baseline. So in many cases, the states need to augment the NASPO requirements with their own unique requirements that are specific to their Medicaid programs, and we're seeing that come through as well. So I think, you know, the reassessment of the states have done on their procurements and the priorities there, as well as the maturation of the NASPO process, have both changed how procurements occur in the past 24-ish months.

It's the perfect storm to modernize that Medicaid So, Stacia, I wanna bring you in now because, you know, you have this viewpoint that it's important for government agencies to remain human-centered, especially during this time. So tell us a little bit about kind of your opinion on that and how Optum is helping to facilitate that.

Sure, definitely. So human-centered design and technology really aligns with what's been ongoing trend in Medicaid and human services, which is a person-focused approach, right? Person-focused approach is really focusing on the individual and their families and the needs and building a comprehensive response to that. Then the government side, moving to that approach has really allowed for knocking down silo walls and aligning that now with technology, really having that same alignment with a human-centered approach. you have all these win-wins happening. You have a win for the state, the payer, better outcomes for the individuals and the families. It's a real win-win approach. But when we talk about what's human-centered design and tech, what does that mean? That's really designing products based on how humans work, how humans think, And it's really based on research and observation. So you don't have a tech person really designing this in a bubble, but instead they have a lens of this human-centered approach. And here at Optum, we really collaborate with state MedicAids and providers because we have this shared human goal. Our mission here is really about people. It's about making health systems work better for people. We understand here human impact and we solve for it. That's evident by the 200 UX designers we have on staff. What we do is to really bring home this human-centered design is feedback loops. Getting the feedback from the users. We're constantly gathering this direct user feedback. We take that experience, we leverage it, we build the product around it, and then what we have is an execution of the product, really hearing the user's voice and hearing the client's goal coming to fruition. I always think of a great example of this. human-centered approach for technology is Optum's provider management module. And so what we really did there is we're listening to the pain points of the states, we're listening to the pain points of the providers, we're taking that feedback loop and really using it to design our product and, and meet the needs of the user and the customer.

Yeah, I love that. It's no longer just, you know, throwing technology out for technology's sake, but really aligning to the needs of the people or the, you know, the human centricity that you've kind of outlined there. So fantastic approach and definitely something that we see as a best practice within the market. So, you know, John, I know these Medicaid modernization projects have historically meant, you know, long timelines and big price tags. Tell us a little bit about maybe the impact of modularity on changing that paradigm or some of those preconceptions.

Right. Yeah. So I think one of the key impacts and benefits that states have thanks to modularity is that they're now able to really choose specific features and functions of smaller, more manageable modules than they previously were when they would need to procure an entire MMIS as a replacement if, if one component aged out or needed to be updated due to regulations or or for other reasons or technology. So that was the norm in the past. And now we see states just essentially cherry-picking the module that they want to advance in its maturity. And that gives states a lot more control over their Medicaid program and where they're spending their dollars to be most effective in their ROI. It also allows states to have a much more specific goal, and requirements can be much more fine and module-specific as opposed to more general as we had seen in the past. So we're starting to see states identify the benefits of modularity and seeing that in their environments and the procurements as those are hitting the market. And in fact, one that recently was on the street gave bidders the option of bidding on several different modules that they were seeking. to replace or mature. And you could bid on one, you could bid on none, you could bid on all. It gave the state a lot of options in terms of what they ultimately will choose when they— as they mature their environment. Now, that being said, migrating to modularity is not easy. Often, we have too many cooks in the kitchen. Those cooks often have competing interests too. So it's really important for, for states to approach this in a pragmatic and thoughtful manner and, and, and recognize that it's difficult in many cases to carve out modules from a legacy monolithic system and make them work within that legacy monolithic system as, as time goes on. However, take just generally the provider module as an example. So we can see now that the implementation of provider solutions are happening fairly frequently now without a complete disruption to the Medicaid operations of that particular state. So in general, the trajectory has shown that the concerns about modularity and the impact on the systems are being are diminishing, and states are really starting to understand what it takes to get that— a modular strategy implemented without upsetting the balance of their universe.

Yeah, I think that's a very smart approach, and it gives them flexibility in the process. So what are some of the best practices as you think about those states that you're working with? What are you seeing being really instrumental to helping agencies be successful with both modularity and maybe the overall modernization of their Medicaid system?

Yeah, that's a great question. So, in general, the biggest thing is preparation. We need to approach the projects with a— like I mentioned earlier— a thoughtful and pragmatic approach to allow states to really take advantage of not only modularity but have a successful project in general. And in my opinion, the system integration layer is one of the keys to success. You know, I like to draw analogies on a lot of things, and we often— home building is where I go to for these. So we often are building a house and we're picking out things like bathroom fixtures before we've even decided on the plumbing. So we need to make sure that we've got the foundational components in place or fully thought through before we start thinking about the modules that will rest on top of those foundations. So in terms of that, you know, Some of the best practices we've seen are that we believe the states really need to consider a data integration approach with legacy systems. They also need to consider the interoperability that will have to occur between multiple vendors and partners. As we're seeing more and more modules make up a Medicaid enterprise, you may have a half dozen vendors that are playing in in that space. So another key component here is the proper ordering of the modules. We can't do claims first. That's, that's an obvious given. But what do we do first? What do we do second? And so on and so forth.

Mm-hmm.

And, you know, as I mentioned earlier, this SI layer is probably the first one that should go in. I believe that deep in my heart. So also, you know, a couple other things are more traditional in terms of project management and project execution. And those pertain to really stakeholder participation and those stakeholders giving timely feedback, as well as the SMEs. These SMEs are critical to delivering on a successful project, and having their participation and commitment to the project is going to help ensure success. Lastly, testing. Testing is the big one. We often short-sheet testing in our project schedules, and we just, you know, we can't do that. So, Stacia, do you have any thoughts on this?

Yeah, you know, when we talk about modernization, top of my mind right now is the state of Iowa. And the reason why is this year they released a series of videos out to the public, the vendor community. They were great. They really were open. They were honest. They were transparent. They did the work and shared in these videos about the challenges they have with the current legacy system. They shared what their data layout looks like. They shared their concerns, their visions, their hopes, their dreams. It was really great. They actually won a Trailblazer Award for this. this work from the Digital Benefits Network. But as a vendor, we really appreciate hearing that information because we're there to solve this with them, right? And their openness for feedback from the vendor community and really looking for partnership. So I could appreciate their attempts and great work.

Yeah, that's great. It seems like, you know, both of you have— are kind of, you know, continuing to echo the human-centric approach, the feedback loops that are necessary in the process. This seems to be a really critical aspect of success, both, you know, pre-kind of implementation when you're gathering requirements and really aligning to those needs, as well as, you know, as you get going, making sure that, you know, everyone is on board and engaged in the process. So really love that approach. So, Stacia, I'd love to get your thoughts on modularity as you think about the opportunity it may present for the providers. Any thoughts on that?

Sure, definitely. When I think about modularity and I think about provider enrollment, right, that provider management component, that, you know, that can be a game changer for some providers. and for some states. So, you know, because currently in some states, the Medicaid office is still using paper for applications, for enrollment, for revalidation, for updates. And so what that results in is the provider having to email or send or fax, and then what that results in for the stateside is more administrative lists for everybody involved really, right? So providers, they want to have an experience similar to what they're having on their commercial side of the business, right? Really streamlined self-service. They want to know when they apply for enrollment into Medicaid what the status of their application is. Sometimes they have patients that they're ready to see. So, right, the timeliness when they don't know what's going on, they're picking up the phone, that's administrative time. So all that compounds into sometimes some provider abrasion, right, which is definitely not what the state Medicaid offices want. Providers are very vocal, right? They're sharing their pain points with the state agencies. The state agencies share those pain points with them. So And they're listening. The state agencies are listening. They're understanding the pain points. They want to streamline as well. So, you know, as we move forward, right, getting those modules put, put a solid module into place that has provider management, you're gonna start seeing that transparency, a high level of communication.

And frankly, it can be a game changer for everybody involved, the state, So as you think about those kind of changes, are these a shift, or is this a shift in expectations? Are these net new expectations, or have these been around and states are just kind of coming to bat to look at solving these today?

Well, I think each state's in its own place, right, of where they're coming to this. This solutioning for this is something that I think has been on the roadmap for a lot of states, and I think a lot of them are getting there right now.

Great. All right, John, final question for you. You know, as we think about the state shifting to, you know, more of a focus on cloud in their technology stack, what advice do you have for them kind of in their position today?

Oh boy, I don't think we have enough time. Yeah, so really, states really need to take advantage of the benefits of a cloud environment. Just moving your operations from your current data center, wherever it may be, into a cloud, you know, I would say that's really not sufficient. That's just a lift-and-shift strategy, and that may actually wind up costing more than your— than the current environment. So I think states really need to look at how they're going to re-architect their environment, their operating environment, so that they can take advantage of those fundamental services like the elasticity that a cloud environment can provide in terms of resource utilization to be able to scale that up and down as demand dictates. Also, you know, migrating to a cloud is going to create a whole brave new world for security concerns. We have to have a very thoughtful and focused strategy as you migrate to a cloud environment so that we're not leaving a backdoor open that we otherwise would not have dealt with in an on-prem solution. So there's a lot of activity— activities that need to occur when migrating to a cloud that may not have been traditionally part of the system development and implementation model. So You know, I, like I said, I probably don't have enough time to go over all the points, but I would say really reiterate those points of, you know, re-architecting your environment to take advantage of what a cloud offers. And then perhaps even prior to that, focusing on security to make sure that we're not creating an issue where none existed before, and that we're also taking into account the threats that are going to come tomorrow.

Fantastic. Well, lots of great information on modernizing these Medicaid systems, and I love the human-centric approach that's really been evident in all of this, especially as we think about, you know, streamlining that provider management component of this. So thanks, Stacia and John, for sharing your thoughts with our wider Government Technology audience on this incredibly important topic. And also special thanks to Optum for making today's conversation possible. You'll definitely want to make sure that you plug into our show notes on this one to watch the replay of this or to get any links to any resources. So check out those. And Stacia and John, thanks so much again for, for spending some time with us today.

Thanks, Dustin. Appreciate being here.

Thank you, Dustin.

We'll see everyone same time, same place next week, 12 PM Pacific time. Thanks for joining In Case You Missed It. Have a great weekend.

Thank you.