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PegaWorld iNspire 2023: Molina's Next Gen Utilization Management Platform – One System Driving Experience, Efficiency, and Effectiveness

Molina has built a Next Gen Utilization Management Platform – all on Pega Care Management. Join this session to learn all about this new solution as it enables the customer to integrate multiple intake channels (EDI, fax, email, portal) to one single system handling prior authorizations, automating workflows, reports, SLA management, and correspondence.


- All right, good afternoon, everyone. My name is Himanshu, and I run the Pega Healthcare Practice at Infosys. Pam.

- Pam Sanborn, senior vice president, Clinical Operations. If you sat in the last session, you heard nurses talking about data. I am finance, talking about clinical. So...

- Joanne Ortiz, vice president of IT technology, and I'm the partner in crime.

- Fantastic. So let's get this started. How many of you know this feeling of being sandwiched between business and IT? Just saying. But it's quite a lot of fun, especially when you have brilliant partners with Pam and William, Pam and Joanne to help do what needs to get done to get the right positive outcomes for the members 'cause that's what matters at the end of the day. You know what's the second hardest thing to do? To be here at 3:15 as a last session and stopping you from getting to the happy hour. Yeah. All right, so with that, let's get this started. I'm gonna probably quickly talk about Infosys. For some of you who might be uninitiated about what Infosys is, we are a 18 billion in annual revenues IT company. Have been in existence for 40 plus years and have been in the top percentages of the best employers, best diversity, best sustainability and so on and so forth. Our healthcare practice is also 10,000 people strong and growing. And we've been the leaders in a lot of our analyst friends who have recommended us for our healthcare services and Pega services. Our Pega practice is part of our low code practice by itself. As you can see from some of the analyst charts, we are the leaders in that side of the house as well, both on strategy as well as execution. We have 7,000 plus people working in this space, and especially on healthcare. We do have a bunch of solutions that we have created over a period of time. But enough said about Infosys, let's talk about healthcare and automation. We did a bunch of surveys in this area and we figured out a couple of items. Everybody wants to do automation. So at least something is 100%. 90% know exactly how to use an automation strategy. So at least they have the plan. More than 65% use bandaids in robotics for automation 'cause they can't get their way across anything else. And finally, 34% of healthcare organizations have been able to implement automation solutions, which have resulted in certain fundamental benefits and the way things get done. And thankfully, Molina is one of them there. What we've seen in healthcare primarily is there's a lot of disparate systems and that's exactly why there is bandaids with robotics all over the place. And don't get me wrong, robotics is not bad for places where it needs to be utilized and used around legacy applications, things which are not API-viable, things which do not want to change and so on and so forth. But for the rest of the world, there is still hope. And for that part of the place, we have organized a framework that we call as the three Es; efficiency, effectiveness, and experience. So if you look at the top side of the triangle, the experience is all about the experiences we give to our members, our associates, our nurses, our care coordinators, our pharmacists, and so on and so forth, our providers. If I'm building an application and automation and not worrying about that experience of how they will end up using that system, I'm doing half a job of it. And remember, when we refer to experiences, we're referring to human experiences rather than just user experiences by itself. Obviously, that's the difference between using GenAI to create this content versus me delivering it out here. That's the difference. Human experiences versus AI experiences. The second part is efficiencies and efficiency is all about being able to get the work done in a better way. If we are not focusing on how efficient we are making our workers who work on those systems to deliver those experiences, we are again not doing a better job at automating all of our systems. The last part, which gets mistaken and missed out every single time is effectiveness. And remember, it's about that process effectiveness. If you are doing claims management, care management, utilization management, any process that you pick up, if you're not measuring the process KPIs and starting to improve them with every single iteration of your implementation, that's the third E that you end up missing. So we took all those three years built around the data and the AI around it and that's what we use in terms of the framework that we use for implementing some of these conversations. So remember next time when you talk about experiences, the human experiences and the efficiency and effectiveness as a process excellence, that needs to go in all of these implementations. Molina did exactly the same where we worked together with Molina to implement utilization management. And to talk more about that, I'll probably invite Pam to do the honors. Pam?

- Yes, actually, Joanne. So Joanne and I are gonna tag team a little bit. That is business and IT. I said we should both have a T-shirt. I'm with her, business and IT, but I think it'll showcase how you need to work together to get the outcomes that we're starting to see.

- Absolutely. So Molina Healthcare, we have a strong focus on providing government-sponsored insurance to a population that's underserved. We have, we're currently in 22 states and growing. We have over five million members primarily within Medicaid, which Pam will speak to in the next slide. Molina has always been focused on the underserved population. That's really been our primary focus since they actually came into existence back in the early 2000s.

- So our mission is really to improve the health of our members, the best that it can be, and really trying to distinguish ourselves as the low cost, most effective managed care company to work for and work with in the markets since we're primarily focused on Medicaid. We are in all three lines of business. So we do work in the marketplace, in the Medicare, primarily duals, and then Medicaid, we're full service. So everywhere from our 10 population, moms and babies, all the way to our most complex members in our long-term support and services. So why did we need to focus on UM? We are not a commercial insurer, so we are highly regulated. Medicaid is government sponsored. So the dollars needs to stretch quite a bit. And if you think about our provider community, we really need to be effective and easy to do business because they're also looking their practices and needing to balance that and we need access to care for those members. So you can go to the next slide. So as we looked at what's our business case, it was pretty strong. And if you look at the right side of the slide, we were heavy manual. We needed humans on every step of the process. Five million members. We do about two and a half million authorizations, we get about five million plus faxes. Every single fax had to be touched by a human, entered into a system. I call it swivel chair. You've heard that a few times today. Swivel over and enter it into a second system 'cause we had a workflow system and then we had the system that processes claims. We had inconsistent adherence to a standard process. Molina does not run a central UM function. It is in all 22 health plans. And so we have to move the entire organization along. We do have standard processes, but once you go into the market, sometimes they feel they know best and they tweak it for that market and then it breaks something, and then the ripple effect. Being a manual process, very difficult to audit, very difficult to find bottlenecks. I could go on and on, but the business case for automation was pretty strong. And really looking at how do we move from heavy manual facts to stronger automation, stronger digital presence. So we could move that along. In the middle of our start of this process, then we had that thing called COVID and went fully remote. And then in the clinical space, we had a nursing shortage. So add on that, trying to maintain clinical staff who have other options, fully remote, just a difficult time, and then comes in a finance person going, "We're gonna put in a new UM system. Get ready." Over there, I'll let IT speak for a minute.

- Oh, we can go back one more.

- Sorry.

- On the IT side we had about 14 plus systems and widgets that supported this process. We had, we went and did some desk audits just to see how cumbersome were the processes or our user experience was. We literally sat there and saw our clinicians with post-IT notes surrounding their monitors, looking up state websites for prior auth matrix. I mean it was a combination of, actually for IT, very embarrassing actually to see just how cumbersome it was for a nurse to get any information on the members so that they could make a decision. So it was important for us to take a look at that end-to-end and understand all these softer nuances in their day to day, including letters, mail, all the various ways that members and providers connected with our internal Molina staff. So when we talk about external data ingestion, it was how do we get that data, and then where does it go? 14 different systems. It was very hard for our clinicians and our coordinators to even know how to put the data together so that they can make a decision. Go to the next one. So based on that, we were looking for a new system, a platform to get away from applications and these one-off systems that addressed small parts and pieces of the process. We knew that we wanted to go into more of a very well integrated, API-oriented platform that would not only combine all of these widgets into a single pane of glass. We also wanted something that was easy to integrate with because we still have other systems. We use Salesforce and another big clinical and claim systems. We wanted all of that data to come to our user. We know it's important for our employees to have a great interaction, especially during our COVID. We knew folks had a choice where they would wanna work and we wanted that experience to be seamless so that they no longer had to rely on a post-IT domain experience, especially when we had a lot of folks retiring, a lot of clinicians that were no longer interested in actually staying with Molina or working. So that was the first thing. And then our business came in and Pam could probably speak to more of the cost benefit.

- Yeah, so one of the things was really looking at the provider experience, right? So when you're in the Medicaid space, we're always focused on the member. But if we service the provider in a utilization management process, the member gets what they need. So we wanted to look how difficult is it to do business with Molina? How clunky is our process? I talked about the five million faxes. We employ nonclinical staff to do all that work. Took at least 15 minutes to actually enter an auth in the system to get it started before a nurse would even touch it. We have many state regulations. Sometimes you have to turn something around in 24 hours, you can have up to 14 days. And so we wanted to look at what's best in class, what would be the best experience for there. So we'll talk about in a minute, right? But we had a goal for the organization. Why are we going through UM? For Molina it was not a lift and shift, it was completely change how we do UM. So we set a goal, we wanted every single auth to come in the building and be decisioned in under 48 hours. That's a big challenge. We're not quite there yet, but we're on our path and that's a much better experience for the provider and definitely for the member. We can go to the next site.

- So when we chose Pega, the benefit of the Pega platform was bringing their healthcare stack into our Azure environment. We now have a Molina enterprise framework. We did that end-to-end process. So we knew our data set, we had to build for a super set. So we actually started with a different component of our organization. The first to go on Pega was appeals and grievances. We took a bottom up view of where do all of your upstream processes land, which we knew was A and G, right? So they're either appealing because they're not happy with the decision or they're calling to complain because they're also not happy with the decisions. So once that went into production, we took a look at utilization management and started to leverage that same framework and started to take advantage of the loco platform and the out of the box functionality. Now, this did include now integration. How do we integrate so that we could produce things like letters? Letters is our number one component that we actually are very regulated on. We have to be able to correspond with our members and providers. We also have to be able to generate and receive faxes. So we knew we needed something that would integrate easily. You can edit from the actual platform and make changes as well because we get information on our members through the state. So you can imagine that the information is probably not up to date. Getting a hold of our members is challenging. So we had to be able to produce something that a person could edit within the application. So this is the functional layer for Molina and how we integrated. It's very high level but it does require all the integration points. Inbound, outbound, and then of course, just internally.

- So how did we start pilot? This is not a big bang effort and you can see the date there, 2021. So we're in our third year, but in 2021, we started with a pilot state. I talked about UM as not a centralized function in Molina with the exception of some specialized UM. That team happens to report to me. So I happen to pick them as the pilot. That's our advanced imaging team. And so we started there, working through that proof of concept. Advanced imaging is a very finite, non-impatient set of codes. So a little bit of the simpler, kind of work through some of the bugs. You'll see the third bullet plan for disruption. We had starts and stops while we worked through, right? I was dreaming big, my IT partners here had to catch up a little bit. You know, it wasn't a lift and shift. So it was some fundamental change in thinking on how we could get there. In 2022, we started to roll out. A key thing here is requirements gathering. And I'll tell you we've probably been on a fourth revision of requirements gathering. So each one, we get better. We took the approach that all 22 states were working on it together. And as we learned something, then we sent 21 of them back to say, "Hey, make sure you're not missing this, you didn't cap, you forgot to tell us about this." I'll tell you a couple of the areas, right? Each state might have refined provider contracts that have little carve outs and they forget to tell you about that. They tend to focus on the regulated rules. And then you have all those contractual rules that will trip you up. We also worked with Pega and the catalyst team. Tremendous service they provide to help you think and continue to iterate on your process. There, worked a lot on the technical components, the guardrail score. So I'm an operator, but I learned a lot about a guardrail. Makes a huge difference rolling out for there. And then in 2022, June, we started live launching for there. And I'll tell you here, in July we'll be close to 50% of our business operating on Pega. And by second quarter next year, we'll be fully on the platform. And then I have, we have lots of things in play to continue to enhance our product there, but right now it's getting that foundation on and sun setting our clunky old systems. The benefit of Pega, no more swivel chair. So it's one system. Our clinicians don't have to go into two. It's talking to both of them.

- The key on the IT side was utilization management prior auths. They touch various departments within the organization. So we had to make sure that other stakeholders who wanted their own changes and have their own roadmaps were also, had in part of the process. So sometimes IT, I don't think it's sometimes, I think it's all the time we have to wrangle in our stakeholders and keep them on point with a roadmap, especially during a transformation journey. It's important because you are still touching parts of their processes. And so governance was key to keep everybody in line and on track. So requirements that came in that were very specific to an authorization process also impacted appeals agreements as an example. So how do we integrate, how do we pull those users in? How do we make sure that changes they're asking for are part of your primary stakeholders' implementation? And this is the only way you can keep moving and try to keep everybody happy.

- So what are some best practices? To piggyback on what Joanne said, one is that governance, you have to have an owner. There'll be many opinions, but you need to be very visible in your organization, who the owner is, and who gets the final yes or no. You have to have someone that is comfortable saying no. That was my job. I came from the health plan side. I'm not a clinician, I'm finance, I lack a little bit of feeling. So I probably can say no a little easier than others, but it was data driven, right? So it doesn't matter how you feel, change is hard, but this is where we're going. The biggest thing is know your end goal. If your end goal is just to lift and shift, that's a completely different path than we took. Our end goal was to be the easiest to do business with, decision everything in under 48 hours. And then I'm finance, so I tucked in, let's have some administrative savings, right? I wanted to remove the humans from the front end of the process. There's no reason to have a human touch, five million faxes. I need them on the backend where you have more issues to look at, where you need more of that. Although listening to AI the last two days, maybe we might need less of those too. This is not a 12-month process and I've heard that consistently through all. It seems like the average is two to three years. That's where we're at. I'll say the next project we start on will go faster 'cause we've all learned a lot. Start with people process. So one of the things we did while we were prepping in IT was looking at what are our 14, 15 systems. In our current state, we weren't optimized in productivity or even following process. So we brought all 22 health plans along in getting them at the top of production. They could be in the current state. Part of that was to get change management. It's coming and I need you productive on the current system because it's going to go warp speed when we move you over. That was about an 18-month period, but we did move the entire organization to a much higher productivity that was also administrative savings. So for those of you that have CFOs out there knocking on your door, that gave benefit while we were asking for money on the other side. Little tip for you there. Standardize that current process, right? So start to get rid of those rogue processes, the urban legends, make sure you're understanding as you're prepping. It helps with business requirements. And robust business requirements. Do not discount that. There's a lot of rework on the IT side if business isn't capturing that. And we can point fingers, but I'll tell you it's business responsibility to gather those requirements on there. Change management, you have to bring your leaders along. It is not easy for nurses and docs to change systems. And I'll tell you the laundry list of complaints in the old system and you need to get rid of it, I hate this, is now the same complaints, you took it away. Now this system works better, but I'm not happy because I was used to my 52 sticky notes on the screen. So they're not happy, but you have to move the organization along. And then very strong IT partner. We could not do any of this and get the value out of it, which I do have a couple numbers for you at the very end, but I'll save them there without having a very strong partnership. And sometimes it's fun and sometimes it's a difficult conversation.

- On the Molina IT side, we absolutely leverage our Infosys partnership to bring in the best practices. And then of course, Pega was there at the table. That was actually a great experience to have such a collaborative and actually, what would be the word?

- Intertwined?

- Yes. Process as we all sat around the table. Of course, remotely because we were all remote by this time. That was actually a nice added challenge was instead of being in a room together and whiteboarding, you definitely had to adapt and do this all across teams, which was just an extra challenge. I think we needed to get this done. But we did. And a lot of that was great conversations. Sometimes they were strong conversations to make sure that we were realigning as we had our couple of first pilot states go live and we had to go back to the drawing board and make sure that we were addressing missed requirements or actually missed items that nobody really thought about until we were live. So doing that type of iterative process and rollout is important because you can continue to fine tune and actually augment the system, which is why Pega's been so powerful for us. We were able to move quickly, pivot, and make sure that we were correcting any issues or problems we had. And then defect management, things that you don't even plan for start coming up. But with this platform, you're able to quickly remediate, get them solved and keep moving. So why Pega's platform was the ideal choice? Because of course, the integration that I spoke about earlier, having this platform, one of the things our architecture team evaluated was if we knew if we went with Pega to support our backend operations, we would have to be all in. We would have to start from that bottom up view and make sure that our stakeholders and the stacking and integration to start to get rid of things like email. You know, we have tons of internal email back and forth between departments. So with using Pega, we were able to not only get our utilization management processes out the door, that is very heavily integrated with our claim system and other systems that support our contact center member and provider services, but we also had to make sure that we were stacking Pega correctly so that our workflows were communicating to each other. That started to reveal a lot of inefficiencies and a lot of unplanned operational lift that we were able to take advantage of. So our ROI was actually started to go through the roof at that point because people that were getting phone calls on an appeal that they were overturning or trying to understand what happened there now could see the data from the utilization management process. We started to implement other workflows as well. Smaller case management workflows. So that stacking really is something that you have to consider as you're starting to roll out because operationally you want your employees to connect with each other within the actual platform. They should not have to leave it or go to email or teams. You can integrate teams, but you don't have to use that as your way of communication. And the other is the rule set. So we also have all of our auto approval clinical criteria integration. We are integrated with Salesforce. We are also integrated with other of our care applications that are doing case management. This platform made it very easy. It was very plug and play. We can actually see the interaction and the transactions monitoring become much more easy for us. And then our letter process, which is external, also became easy to monitor and we were able to communicate for the first time where things were, what the status was, if the letter actually went out the door, if it's on time, if it's stuck pending, and so forth.

- And if I may just add to that, a lot of times people forget, but based on the regulatory and the compliance needs, the ability to go trace the rules back. And hence the industrial strength rule engine versus, in a lot of other places we've seen actual business rules emitted deep inside logic and code. If you had to go and do an audit or trace it back, well, wish you luck. But those are some fantastic places where Pega just stands out all day long.

- Yeah, you wanna speak to this one?

- Sure. So what are some of the best practices as we went through the program from a technology perspective? I think Pam and Joanne have covered a lot of those conversations. But first things first, a digital first approach to getting this entire thing stood off the ground by itself. Remember the five million touches in the front end by itself, right? If you had to digitize it all upfront, that's the core fundamental. If you had to digitize it, do you also digitize it with a human experience, as well as the process efficiencies? Because that's what's gonna give you the cost savings at the end of the day, right? So being able to look at it from a digital first lens with the right human experiences and the process excellence built in. The second is, even though you chose Pega, are you gonna end up customizing it? Are you gonna put up some stuff, which is gonna only make it harder for you when it's time for upgrade or are you gonna use a lot of out of the box? And Manoj just smiling out there, but yes, Manoj. Right?

- [Pam] You're gonna use out of the box.

- Out the box.

- In business, you're gonna use out of the box.

- Yes. Then as you go through, because this is not a quick, let's get it done, three months, six months life cycle, it takes a couple of years, right? To get it done. And hence the ability to reduce the cycle time as we go along every single iteration of this implementation, that takes a lot of conversations both in terms of how the system is set up, how the configurations have been done, as well as the ways of working, right? Pam spoke about how we got better with every time we collected requirements across the board, right? And those situations went in. So fostering the reduction in cycle times such that everybody gets excited about the momentum that we are generating along the way and then learns from it. Yeah? The third piece of the puzzle is in the core, core development and the reviews, the entire guard rail scores, right? The entire ways of configuring Pega so that it's as per the right best practices, design patterns, naming conventions, guidelines. And it's important because it's a long journey and Pega has so much power as a technology that if you get it configured the wrong way, it can have some serious one along the way. So it's very important to put in those right reviews in governance mechanisms. The last part of this complexity was also when you have to run Pega on a private Azure cloud and not on the standard Pega cloud. It has its own nuances to this entire world of making Pega work on an Azure environment and being able to do the right DevOps and CI/CDs and pipelines and deployments and infrastructure management around it. It helped that Infosys was the infrastructure partner of choice for Molina as well. And hence we were able to bring some synergies along those conversations to make life easy. The last part obviously is around the adherence, compliance, and change management. As you can very clearly see, the right ability for business and IT to come together to collaborate is a core fundamental reason why Molina is where it is today. And then being able to adhere to the right best practices, being able to work together as a solid group working within forces and Pega together in the room such that all of us have one shared vision and not each of us has different objectives by itself. I think that's a fundamental core to how technology can even start to behave in these matters. Pam, wanna add something?

- So the numbers, right? Many of you're like, "Well what have you achieved?" So we started last June and I'll tell you, our first four launches were really pilots. We launched the very first pilot with our advanced imaging team. Then Molina's in a growth mode, so we happened to buy a couple health plans and we wanted a new state. So we had some standups. With each of those implementations, we were refining, putting enhancements, or a new feature was plugging in. But so far, we removed anywhere from six to nine minutes for that front end fax off the machine into Pega. So when you do your math of six to nine minutes and you can lean to the higher end, times five million faxes, you can start to see the value in that space. And we're seeing close to five minutes on just basic foundational benefit for our nurses. We're doing a few enhancements, so we haven't measured our doc satisfaction 'cause they keep moving the bar on us a little bit for there. Our very first, what I call plain Jane implementation, legacy health plan, nothing special came up last month. They are running right at pretty close to productivity. We had very little to no defects, very little complaints. And we are seeing, right now at the gate, being able to get an auth built in under three minutes. Now, we'll watch it over a little bit more time, but just giving you a feel for the amount of value you can quickly get out of a pure kind of production shop. And we probably have about 20, I have at least probably 20 or 25 things that we know we can enhance, right? Automating, looking up benefits, and all kinds of other things around provider records. That's just core processing. So tremendous value, tremendous amount of efficiency. And for a company where you're in growth mode, it's not about, right, that admin cost, you're just moving it along to the next place and keeping finance happy for there. So it's been a long journey, but very exciting. So we're really excited to get everyone on the platform by second quarter, and then start on the next layer of things.

- And you're gonna add a 26th one because no conversation is complete in PegaWorld now without talking about generative AI.

- Right.

- Yes. And I saw some demos and my brain's-

- Probably don't bring your stakeholder to see those types of things.

- Yeah.

- 'Cause now that's on the roadmap.

- So we'll add the 26th thing in terms of maybe adding a good care summary-

- Yes.

- Generated by generative AI based on all the fundamentals such that when the RNs are supposed to call somebody, they don't have to look at everything else, get ready for it-

- Right.

- And then generative AI can do the trick as an example.


Industry: Healthcare Product Area: Customer Service Product Area: Intelligent Automation Topic: Business Agility Topic: Low-Code Development Topic: PegaWorld

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