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John SupraDeputy Director

Operations and Information Management and CIODepartment of Health and Human Services, South Carolina

Beyond Enrollment to Improving Quality of Care

Eligibility & EnrollmentJust a First Step

John Supra, Deputy Director & CIOSC Department of Health & Human Services

IBM Health and Social Programs SummitOctober 21, 2014 – Washington, DC

Modernizing Eligibility SystemsSC Eligibility

•Moving from 100% Paper to Online•Enabled Statewide Staff to Process Eligibility•Since October 2013>Nearly 320,000 visits for 189,000 unique visitors>Over 92,000 citizen accounts created>Over 51,000 of 294,000 applications online (17%)>Processed nearly 40,000 applications from FFM

• Next Steps>Non-MAGI populations>Renewal processes

Online is Great But…SC Eligibility

Aren’t we just catching upto the rest of the economy and consumer

expectations from10 years ago?

“The real voyage of discovery consistsof not in seeking new landscapes,

but in having new eyes.”

Marcel Proust

Eligibility – Applications, Renewals & Decisions

Just a First Step – In Process

Just a First Step – In Process

Eligibility Plan Enrollment

Everything Else – That is Possible

Elig

ibili

ty

Plan

Enr

ollm

ent

Prov

ider

Cho

ices

Sche

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g

Just a First Step – In Process

Just a First Step – In Population

SNAP 44.7

M

Development

Disability 32.5M

Medicaid

68M Head Start

1 M

Unemployment

8.4 M

WIC9.2MTANF

4.4M

LIHEAP 4.9M

Child Support

40 M

Foster Care 500K

Housing Assistance

4.9M

Health & Human Services ServingOne-Third Population in United States

Sources: Data – CMS, ACF, FNS, Census bureau websites; Concept – Stewards of Change

• Lack Unified Data on Citizen Interactions> Across health and human services programs>With other state and federal agencies> Core “CRM” – treating citizens like your best customers

• Lack Unified Case/Clinical Data> Eligibility, enrollment, case plans and services> Across programs, payors and providers

• Inappropriate Data Reliance >On administrative and claims data

But We are Still Behind…

Not Enough

• One Driven by Social Determinants• One Focused on Outcomes> Population Health – individual, family, community> “Value” Driven – Aligned with Triple Aim

> Cost – Reduce per capita cost of health care> Effectiveness – Improve the health of populations> Experience – Improve the patient experience

• One Grounded in Local Communities• One Enabled by Technology

Bigger and Brighter Vision

Think Different

“The average person today processes more data in a single day than a person in the 1500’s

did in an entire lifetime.”

The Human Face of Big DataRick Smolan & Jennifer Erwitt

“Don’t Cross the Streams”

Streams

Scene from Ghostbusters, copyright Columbia Pictures

What are Our Streams?

Streams

•Silo’d Policy Streams•Isolated Funding Streams•Duplicative Streams for Citizen Interactions•Duplicative/Conflicting Delivery Streams•Stream Challenges at State & Federal Levels

“One of the most common tendencies of human nature is that of placing responsibility on some external agency for sins

we have committed ormistakes we have made.”

Attributed to Dr. Martin Luther King

Technology as an Accelerator

Technology

• Citizen and Worker Driven Processes> Enabling self-service, automated services> Complete re-thinking of processes and process-design> Planning for a mobile future

• Data-driven and Predictive Analytics> Enables “siloed” data to be used across the enterprise (and beyond)> Toward automated and dynamic analytics, away from reporting> Toward payment reform (what we pay, episodes of care, risk sharing)

• South Carolina Efforts> Toward a “purchaser of health” not a “payor of services”> Healthy Outcomes Program (HOP) – high need uninsured> Pay-for-Success for maternal and early childhood home visiting

• Using A-87 Cost Allocation > More flexible than most believe…

• Thinking about the Enterprise & Interop> CMS support for enterprise planning> Need to provide, support and consume “services”> Interoperability frameworks

> CMS/MITA, ONC (heathit.gov), Human Services (APHSA & stewardsofchange.org)

• Efforts on Data Sharing Agreements> Templates and best practices (NASHP)

• Federal Leadership> HHS IDEA Lab (www.hhs.gov/idealab)> CMS Innovation Center (innovation.cms.gov)

What Can We Do Today

Today

• Capacity> Intellectual curiosity, expertise and skills> Systems, tools and access/use of data sets

• Vision and Direction> Understanding of what is/may be possible> Leadership prioritization

• Culture and Mindset> Around data-driven decision making> Around risk-taking> Around making novel connections

Thinking about Tomorrow – People

Opportunities

• Capacity> Flexible, dynamic, on-demand computing (cloud)> Liberated data

• Vision and Direction> Framework and platform thinking> “Service” infrastructure

• Culture and Mindset> Fast delivery and willingness to iterate> Enabler vs. inhibitor> Managing “hybrid” or “bi-modal” development

Thinking about Tomorrow – IT

Opportunities

“As we find new ways to use computers, they won’t just get

better at the kinds of things people already do; they’ll help us to do what was previously

unimaginable.”Zero to One

Peter Thiel

Questions & Discussion

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Jessica KahnActing Director

Data and Systems Group Center for Medicaid and CHIP

Beyond Enrollment to Improving Quality of Care

Medicaid- Beyond Eligibility and Enrollment

Medicaid- Beyond Eligibility and Enrollment

Jess Kahn, MPHDirector, Data and Systems Group,

Center for Medicaid and CHIP Services,Centers for Medicare & Medicaid Services

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OverviewOverview

• Reminder: what’s the vision• Step 1: eligibility• Step 2a: enrollment• Step 2b: access to high quality care• Step 3a: care coordination and payment

models• Step 3b: coverage + health care services + ?? =

better health and well-being

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The VisionThe Vision

• Better individual health (and well-being)• Improved population health • Lower costs

• Health insurance coverage isn’t enough on its own

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EligibilityEligibility

• Still to come- bells & whistles– All states with pre-populated online renewal forms– “Change in circumstances” and “benefit

management” mobile apps– Application mobile apps– More real-time eligibility determinations

• Expanded automated verification sources

– More integrated systems with human services• E.g. multi-benefit applications

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EnrollmentEnrollment

• Still to come:– Faster transactions for enrollment– Can a SBM do automated enrollment for MCOs

too? Plan compare for MCOs?

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Access to CareAccess to Care

• Requires good data availability and analysis to map provider resources and utilization

• What about continuity of care when there is a transition in coverage (between Medicaid and QHP or vice versa)? – Overlap of provider networks between MCOs and

QHPs? – Transition (with consent) of beneficiary data

between plans to avoid disruption in care management

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Care Coordination/Payment Model Reform

Care Coordination/Payment Model Reform

• Increased enrollment = increased demand– Efficient use of resources– Right incentives for better care/ outcomes- based– Luring “new” Medicaid providers

• How easy is it for a provider to enroll in Medicaid?

• What about the role of HIT/E? – How HIT-enabled are providers serving the newly

covered? In general?

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What else drives health?What else drives health?

• Integration with human services– Better consumer experience (operationally)– Lower IT investments– But… what about the consumer’s overall health outcomes?

• Integrated case management• Predictive modeling

• What else should be considered for integration with Medicaid/CHIP data to meet the triple aim? – Juvenile Justice?– School health?

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How?How?

• Smart technology– Software as a Service and COTS– Enterprise Service Bus– Enterprise Data Management/Warehouse/BI Tools– Enterprise Identity Management

• Smart IT architecture– Enterprise Data Models– Modularity– Don’t fear the Cloud

• Smart IT Procurement31

Questions?Questions?

• Contact information:– Jessica.kahn@cms.hhs.gov

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