More than 90 million enrollments in Medicaid and CHIP were reported in
September 2022.
In fact, the number of beneficiaries covered by the Medicaid program increased by 40% back in
2018 and covered about 73 million, from 55 million since the time the affordable care act
was passed. This growth has attracted more health insurers, healthcare service vendors,
provider-led health plans, and investors to the program. Along with that, the COVID-19
pandemic has also increased demand for Medicaid programs as they expedite coverage for
eligible individuals.
Growth in Medicaid is expected to continue on the upward trajectory as the program expands to
accommodate the complex high-needs populations into managed care. Efforts to improve
Medicaid enrolments continue as states explore ways to implement tech innovations to managed
care models to improve quality and efficiency, increase budget predictability, and control
costs.
Medicaid aims to be a trillion-dollar program by 2026. It also promises to cover a much
wider demographic with capabilities that are deeply tailored to meet the needs of every
subsegment.
The program that now covers one in five Americans, including many
with complex and costly needs for care, is extremely focused on growing enrolments. However,
a new influx of enrolments can be debilitating for legacy, back-end infrastructure.
Modernizing Medicaid and shifting from monolithic Medicaid Management Information Systems
(MMIS) to modular Medicaid Enterprise Systems (MES) is now essential.
Along with
this, modernizing Medicaid programs will demand a focus on the following aspects.
Crossing the Data Chasm
Medicaid programs have to be aligned with each state’s standards of eligibility and how they
address the health needs of their population. Apart from addressing needs like long-term
care support, mental health, children’s and women’s health, etc., many states have
outsourced care coordination to private managed care entities. These privately managed care
bodies are often reluctant to share data which limits the availability of timely clinical,
financial, and administrative data for overseers. The absence of real-time data further
makes it hard to manage and monitor enrolments.
Modernization plans, as such,
must focus on improving access to and analysis of clinical, administrative, and operational
data. Improving data and analytics capabilities can provide valuable insights into program
performance and address population health needs more accurately and proactively.
Standardized, Automated, and Modernized Process
Standardizing, automating, and modernizing processes is another aspect that needs to be
covered in the journey to
modernization. Implementing standardized, automated, and modernized process enables
easy management and retention of critical enrolment information across multiple business
lines.
Modern, scalable, automated, end-to-end enrollment management solutions
become essential to support growing Medicaid needs. They also consolidate enrollment data
across partners and drive automation for greater visibility. Further, they relieve IT teams
from sorting through siloed sources of member data while also driving timely communication
and issue resolution.
Modularity Is Essential for Operational Transformation
Most Medicaid programs rely on dated, legacy monolithic MMIS systems. The Enterprise Data
Warehouse (EDW), Independent Verification & Validation (IV&V), Pharmacy, and
Integrated Eligibility all lie in separate modules in a majority of the MMIS systems. As
Medicaid agencies feel the need to improve outcomes and increase transparency, modularity
becomes a crucial goal for modernization.
Modular systems become even more
essential as new regulation adherence becomes essential for compliance and data availability
increases. Monolithic, legacy systems do not offer the flexibility and agility needed to
improve operational effectiveness and costs.
Modular systems are more
extensible and offer greater interoperability. They can connect key stakeholders, streamline
processes more effectively and provide greater and more secure information access, thereby
driving operational transformation.
Configuration or Customization – Making the Right Choice
The conversation on modernization almost always veers toward customization. It is the same in
the case of Medicaid as well. Modernizing strategic business processes might warrant more
customized processes. Combating fraud or improving delivery and payment capabilities might
warrant customization of systems and processes. However, sometimes customizations can be
limiting and expensive.
While driving innovations in areas of say, delivery, and payment, are warranted, opting for
configurability and identifying the ideal candidates for the same in the modernization
journey can offer distinct advantages. Employing a well-built, robust, and comprehensive
configurable system on a modular, cloud-hosted platform offers many benefits. New feature
adoption, scaling the user base, managing load, driving availability and adaptability also
become easier and less expensive with a configurability focus.
Process Automation and Information Sharing
Medicaid modernization is not just about technology but about driving enablement. Be it
members, workers, providers, managed care organizations, and other business partners, the
modernization efforts have to help these stakeholders capture, share, and use information
effectively, efficiently, and securely.
Intelligent process automation will
become essential to quickly and accurately process millions of documents to serve the
constituents and also meet deadlines. However, it is important to ensure that the automation
solution automatically classifies, extracts, and enriches data from any document type,
regardless of structure, quality, and text type. It should also provide a high degree of
accuracy, customization opportunities, and fast, easy, and secure deployment.
Process automation reduces manual effort and improves accuracy. It drives reliable, accurate,
and timely information sharing that makes claims processing faster, reduces waste, improves
costs, and prevents fraud.
Mobile Enablement
Studies have previously revealed that 86% of the general adult
population and Medicaid beneficiaries (both) use smartphones. Most Medicaid users also use
mobile technology to manage their health. 37% of the users, for example, measure fitness and
health improvement, 27% monitor health issues such as blood sugar, and 24% receive alerts or
reminders to take prescription drugs, etc., through their smartphones.
Even
low-income beneficiaries use smartphones. Mobile enablement and mHealth applications can
play an integral role in driving greater access and improving care for the overall
population. Mobility lowers costs, improves quality, and increases access to care, even for
rural and underserved populations.
Mobile health apps can also better track
medication needs and dosage instructions, send alerts and messages for chronic disease
management, and offer healthcare providers and specialists more means to communicate
effectively and coordinate care better.
In a Nutshell
Kyyba acknowledges the obstacles confronted by Medicare customers and is dedicated to
delivering comprehensive solutions that cater to their requirements. Through our proficiency
in healthcare technology and streamlining processes, we can assist customers in simplifying
their enrollment and eligibility verification procedures, capitalizing on Ai driven process
automation to enhance productivity, as well as improving data management and
information-sharing practices.
Our adaptable and customizable solution approach offers versatility, scalability, and
compatibility to ensure a seamless transition toward modernized platforms. By leveraging
mobile integration be it Native Apps or Hybrid apps built mHealth applications connected to
EHR systems, we can empower customers with the ability to enhance access to healthcare
services while promoting patient engagement through effective communication and coordination
among healthcare stakeholders.
Collaborating with Kyyba within the Medicare sector has the potential for better results,
heightened efficiency levels, as well as enhanced accessibility of healthcare services for
both customers themselves as well as beneficiaries. Get in touch with us today!
