Modernizing Medicaid: How technology is readying the new workforce era and improving provider participation + patient access

Healthcare continues to grapple with employee burnout, anticipated waves of retirements and limited prospective candidates with the requisite skills for both clinical and administrative positions. The healthcare “brain drain” is real and it presents challenges for Medicaid programs. As hiring and retaining state employees becomes harder and fewer providers participate in Medicaid programs, access to healthcare for states’ most vulnerable populations could be in jeopardy.

Becker’s Healthcare recently spoke with three experts from Gainwell Technologies — Aneesh Kumar, chief product officer; Gary Call, MD, chief medical officer; and Jeff Reid, senior vice president of Medicaid management — about the current Medicaid landscape and how modernizing Medicaid management systems can help alleviate workforce-related pressures that stakeholders face in this important public health insurance program.

Competition for talent and provider abrasion are worsening Medicaid workforce challenges

When it comes to managing the Medicaid program at the state level, institutional knowledge is dwindling. Between 2017 and 2021, 46 percent of state and local public health employees1 left their organizations. If this trend continues, by 2025, close to 130,000 people2 will have resigned.

Additionally, private sector competition is fierce for individuals with skills like population health management, data science and information technology. This has led to a reduced ability to modify and maintain critically important Medicaid management systems.

“Many of these systems were developed years or even decades ago,” Mr. Kumar said. “They are often not well documented, and newer graduates don’t have relevant programming skills. When experienced employees leave due to retirement or burnout, states have to scramble to address their Medicaid program objectives.”

Mr. Reid agreed. “We need expertise to drive program adoption,” he said. “If you don’t have the talent in place to develop and analyze programs and then drive next steps, Medicaid programs falter and don’t generate the desired outcomes.”

On the provider side, the complex systems and processes required to serve Medicaid members are overwhelming physicians. Most states now use Medicaid managed care entities to handle benefits for members. A single state may rely on more than a dozen different managed care entities. If Medicaid beneficiaries change their managed care plan, which they can do frequently, their medical history may not carry over from one plan to the next.

“When a clinician’s Medicaid population comes from half a dozen or more managed care organizations that all have slightly different processes, it really fragments workflows and adds to provider administrative burden,” Mr. Kumar said. “Providers also have to incorporate information from managed care entities into their electronic medical record system, which isn’t the easiest system to begin with.”

Medicaid patient enrollment, coordination of benefits, prior authorizations and reimbursement are all sources of provider abrasion. On top of these processes, it’s next to impossible to coordinate across providers or obtain analytics about patient risk profiles, which would enable physicians to treat people in more effective and cost-efficient ways.

“There are a lot of obstacles to being a Medicaid provider,” Dr. Call said. “Many physicians participate in the program out of a sense of social duty. But, every time it’s inefficient, they’re less excited about being part of that. Sometimes, providers eliminate the lowest payers or the payers who are the most difficult to work with. If that’s Medicaid, it impacts access to care. It’s imperative that we make Medicaid systems easier to use.”

System improvements can increase Medicaid efficiency and the stakeholder experience

These challenges call for modernized and simplified Medicaid management systems. Modernization of Medicaid management systems focuses on general improvements to information systems and workflows, while modularity focuses on creating cutting-edge systems. “Traditionally, Medicaid core systems have come from two or three vendors,” Mr. Kumar said. “The hypothesis is if you can break systems down into smaller chunks of functionality and smaller procurement initiatives, there will be greater competition.”

System integration platforms are a promising area of innovation. These tools promote interoperability and workflow standards. In the Medicaid field, Gainwell Technologies has codified its domain expertise into solutions. “We know how to connect the dots across different parts of Medicaid, and we serve as a systems integrator for our own modules,” Mr. Kumar said. “That helps us as we help Medicaid management ecosystems that include vendors other than Gainwell.”

Application programming interface-first software is another important technology advancement. This type of software enables different systems to create contracts with one another related to the data they will provide and consume. “With API-first software, one system doesn’t need to know about the languages, databases, frameworks, libraries and various aspects of other systems,” Mr. Kumar said. “API-first technology systems, combined with system integration platforms, are enablers of best-in-class Medicaid management solutions.”

To improve efficiency, self-service can also play a significant role. The goal is for stakeholders to easily navigate the system and access information to support fast, efficient decision-making. Data science, machine learning and artificial intelligence are all technologies that will support self-service benefitting both providers and members.

“To grow Medicaid programs and provide better service to citizens, you need the ability to scale and adapt technology,” Mr. Reid said. “A good example is AI and automation. Deploying AI in a call center, for example, would allow beneficiaries to self-serve and obtain answers to questions without engaging with a human. Automation could also be used when providers contact states with questions related to reimbursement.”

Technology alone is not enough to reinvent Medicaid management

Technology is a critically important enabler for modernization of Medicaid management, but it’s not a silver bullet solution. To support Medicaid modernization, business processes and organizational cultures also need to change. States must prioritize the modifications that they want to make and then compartmentalize them.

Prioritization is often done in conjunction with a roadmap that defines how organizations will achieve desired results. “It’s essential to identify areas of change that will deliver value without creating high levels of risk,” Mr. Reid said. “Changing core claims, for example, introduces significant risk and might be placed later in the roadmap.”

Governance is also a key consideration because it influences how efficiently work gets done. Teams must determine whether the right processes have been implemented and whether the right conversations are happening. “People need to understand how decisions impact their roles,” Mr. Reid said. “They also need to understand which goals must be achieved to declare success.”

Take a step back before moving forward

A third best practice is developing plans to deliberately test and learn during system and platform updates. It’s essential to compartmentalize changes and test them before moving on to the next change. Working in incremental steps is the best way to achieve modernization objectives.

As states modernize their approach to Medicaid management, it can be helpful to take a step back and consult with industry partners about best practices before writing requests for proposals

Doing nothing is not an option — the stakes are too high

In many states, Medicaid is the largest state government expenditure, and budget numbers continue to grow. Without modernization, ongoing inefficiencies will increasingly contribute to higher healthcare costs, fewer providers who are willing to participate in the Medicaid program, and reduced access to care for members

“Leaders of Medicaid programs and systems would be wise to focus on program outcomes and the societal promise that Medicaid has made,” Mr. Kumar said. “Rather than spending more money, let’s modernize program delivery with best-in-class systems based on new technologies and innovative players. Our focus should be on creative solutions that we can use to deliver on Medicaid’s promise.”

Greater Medicaid efficiency benefits providers, members, and state organizations alike, and can be a powerful way to retain top talent. Technology-based solutions that enable automation, self-service and streamlined processes can improve workflows and ease administrative burden. But more than that, these solutions can help states maximize the talents of their teams — allowing them to focus their specialized skills on higher-level problem solving and more impact-driven work. This, in turn, creates more exciting careers and inspires a happier, more engaged workforce.

“Our nation’s healthcare goals are quite enormous,” Mr. Reid said. “Modernization allows the Medicaid system to achieve those goals in the most effective and productive way. That’s where Gainwell comes into play — our technologies and expertise are enablers of modernization aspirations.”

Dr. Call agreed. “We can’t change the reimbursement piece of Medicaid, but as a company providing technology to state Medicaid organizations, we can make sure to provide a great user experience for those who interact with our systems.” 

1Leider JP, Castrucci BC, Robins M, Bork R, Fraser MR, Saviola E, Piltch-Loeb R, Kohn HK. (March 2023). The Exodus of State and Local Public Health Employees: Separations Started Before and Continued Throughout COVID-19. Health Affairs. DOI: 10.1377/ hlthaff.2022/01251

2Leider JP, Castrucci BC, Robins M, Bork R, Fraser MR, Saviola E, Piltch-Loeb R, Kohn HK. (March 2023). The Exodus of State and Local Public Health Employees: Separations Started Before and Continued Throughout COVID-19. Health Affairs. DOI: 10.1377/ hlthaff.2022/01251



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