Last year, my wife and I moved from Pennsylvania to Vermont carrying hundreds of boxes, four children, two dogs, a large ginger cat, and one live-in veteran father-in-law on disability. This relocation, in addition to being physically taxing, meant that we also had to change medical care providers. Doctors, dentists, optometrists…the list goes on (and on). I had to find new in-network providers, make appointments, and source medical records for myself, my wife, and our four kids.
However, due to HIPAA security requirements, our ex-pediatrician's office could only accept record requests in two ways: fax, or mail. We had to wait twice as long to receive our children’s records because one request was rejected for “incomplete dates,” although all four forms were identical. The whole process took four months. One short drive to their new pediatrician's office to deliver them (due to their inability to accept digital transfer), and then just a final six weeks wait time to get them their first appointments. Straightforward, right?
I’ve delivered expert government systems for the past 11 years as a business rule engine expert, helping design and develop Medicaid Eligibility & Enrollment (E&E) solutions across the United States. I know that what I faced in trying to access healthcare services were multiple customer service walls. The providers’ offices were not technologically equipped to facilitate better care for their patients. They could have improved ease of access by having the ability to receive and send digital records, reduce service wait times, or ensure that my records could be stored and transferred securely under HIPAA compliance.
The burden to overcome these customer service walls in healthcare -- whether it be lack of digital access channels, disconnects between sources of healthcare data from one provider to another, or inefficient internal case management processes (to source healthcare records for new patients, for example) -- falls on the patient. Patients can potentially overcome these burdens if they have the proper resources, although not necessarily quickly. Without resources however, as may be the case with the 88 million individuals receiving Medicaid in the US as of April 2022 (about half of whom are children), those barriers are no longer inconveniences - they become insurmountable.
Software which accurately and effectively handles hundreds of enterprise system processes, works under stringent and ever-changing compliance standards, and scales to handle the life changes of millions of state-wide members cannot be bought ‘off the shelf.’
Since the implementation of the Affordable Care Act (ACA), many State Health and Human Service agencies have utilized large teams of specialty technical resources to create their Medicaid Enterprise Systems (MES). Since MES solutions cannot be bought ‘off the shelf,’ custom construction (or advanced configuration and tailoring of an off the shelf software) has been a necessity to create systems which handle the level of complexity required. This has largely resulted in two types of MES:
- Monolithic: Massive, specialty applications, typically built under a sole or controlling systems integrator. Once built, they can be difficult to modernize as technology advances, as they are limited to the initial procurement's functional scope (even during add-on option years).
- Modular: Smaller procurements based on objective outcomes (such as increasing the number of real-time MAGI determinations performed). These smaller procurements allow for functionality to be acquired or replaced in smaller projects. (This is a cost stewardship method promoted by CMS Outcomes-Based and Streamlined-Modular certifications.) While these smaller applications (relative to monolithic) add agility for measurable, achievable, and short-term needs, they are still a reactive approach to change.
Both MES methods are limited when anticipating change. Why? Because all are reactively adapting to existing member needs through a slow, multi-year, usually multimillion-dollar adaptation process. As a result, service delivery can be limited or behind barriers for people during times of critical need.
So, what do we do? We build for change.
Metaphorically speaking, reacting to change could be thought of as purchasing an umbrella after it has started raining. Anticipating a need would be reading the weather report and purchasing one in advance. Anticipating the unanticipated means adopting structures, strategies, and methods which move Health and Human Services away from the rigidity of traditional development cycles. It requires focusing on re-useability, sustainability, and structurally anticipatory models. Some of the world’s best and biggest enterprises in customer service industries utilize software which can handle both their process complexity and allow them to build for change. These are some steps organizations serving members can take to shift into more proactive models of adapting to change:
1. Shift away from objective-based procurements and towards a continuous automation model.
Continuous automation incorporates ongoing assessments of technical feasibility, prioritizing immediate high business values and ensuring that each outcome delivery occurs in 90 days or less. Focusing on deeper granularity in delivery and ongoing releases (at Pega we call this minimum lovable products) can help agencies proactively address change, rather than respond to it.
2. Adopt a center-out approach to objectives, which places the emphasis on incremental improvements to current processes.
This means leveraging the most powerful force in all government agencies – your workers. Low-code tools can be utilized to transfer business process creation from the hands of traditional developers, who are separated from the day-to-day actions of the agency, into the hands of business administrators. Folks that know the job best can not only create workflow processes to make their jobs easier but also adapt them as circumstances change in real-time. When combined with a continuous automation development approach, this empowers your agency to take your existing processes and create incremental positive changes.
3. Cyclical delivery methodologies (such as Agile and DevSecOps) are necessary to a continuous automation approach -- but must be applied effectively.
Transferring white-board post-it notes into a technical development plan or getting business users to accurately record bugs and feature requests are hard to achieve and create barriers to IT delivery. Pega supports agencies with real-time, in-app requirements gathering and user story capture through our Agile workbench, or via integrating an agency’s existing tracking system such as JIRA.
Stakeholders can provide feedback and requirements from right inside the app, which then automatically translates the feedback into agile artifacts for the IT delivery team. Built-in Pega Express provides time and level of effort estimates for delivery and tracking. Pega Express also generates realistic outcome-focused continuous automation cycles, enabling teams to tackle massive objectives as granular, achievable micro-changes.
4. Leverage existing enterprise technology, when available.
The healthcare industry must comply with many complex regulations and policies. For example, when addressing the Centers for Medicare & Medicaid Services (CMS) Interoperability rule (which requires that State agencies meet new technical requirements to implement and maintain standards-based Patient Access API by 2025), healthcare orgs can leverage software which already offers patient-focused care management compliant with Hl7 FHIR standards and HIPAA requirements. This saves time, money, and speed to successful compliance.
5. Rethink business architecture that limits future adaptations.
By starting with the workflows driving operations in your MES, you have adopted a center-out model which can incrementally leverage new ways to handle those steps. Manual eligibility determinations can now leverage intelligent automation. Robotic process automation can now address form fills or cross-application gaps, and you can even create 24/7 self-service for your constituents. With a solid foundation, you can replace manual process steps incrementally with modern technology and scale without re-inventing your core workflow or disrupting access. These improvements help your members and case workers by reducing service time, removing repetitive and unnecessary tasks, and removing barriers to access.
Frequent legal changes to healthcare laws, public health emergencies, and economic fluctuations all have the potential to severely effect America’s most vulnerable and disenfranchised communities in the coming few years. Americans require (and deserve) systems which can change on a dime, so additional barriers are not erected for people seeking healthcare and other government services during critical times.
Cut complexity. Coordinate care. Make a world of difference.
Deliver patient-centered outcomes to your entire population.
Governments Building for Change
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