Medicaid Modernization: Aligning Business Strategy with Human Outcomes

Imagine embarking on a cross-country road trip without a destination in mind. You've got maps, snacks and a full tank of gas, but where are you going? Similarly, as states gear up to modernize Medicaid, jumping into creating a tech roadmap is like planning that trip without knowing the destination. Modernizing health and human services is crucial for meeting federal mandates and adapting to the evolving needs of communities. Yet, it's not just about picking the latest tech for the journey.

Determining the Optimal Endpoint

At Gainwell, we’re seeing states find the greatest success when they align their Medicaid IT modernization roadmaps to the end results they desire in their overall Medicaid programs. Closely examining existing business processes, identifying opportunities for optimization and employing technology as the enabler ensures that systems and operations are aligned toward program outcomes. 

Just as the starting point is different for every state, so is the destination. No one route will lead every state to the same outcome. Rather, state-specific business needs and priorities will determine the best path forward. 

These business needs vary from program to program, but there are some common themes and trends we’re seeing that are driving the need for technological enhancements across Medicaid programs. These considerations, in turn, are helping states determine where to focus their modernization efforts. 

• The shift from fee-for-service to managed and value-based care. Most Medicaid systems were originally developed to handle large volumes of fee-for-service claims, but states that are shifting to managed care and value-based care models may need to either modernize their existing systems or replace them with newer technologies. The shift toward integrated, patient-focused care models, utilizing capitation and incentive-based payments, has states reevaluating their current claims processing systems. 

• Self-service and user experience. States can improve member engagement, drive higher use and create greater user satisfaction by enhancing member- and provider-facing portals and user interfaces. It’s a high-impact effort with moderate investment, that can transform the digital user experience.

• Focus on the person. As states work to improve health outcomes at population scale, they must equip systems to accommodate multi-source data and perform advanced analytics. This will enable the creation of longitudinal health records that support preventive, actionable and measurable interventions. 

Asking Strategic Questions

Identifying desired outcomes at the outset of a modernization initiative and asking questions about how best to achieve these goals will help ensure alignment throughout the project. Since these goals are specific to each state, modernization approaches will vary.  

• Define near- and long-term outcomes to better serve citizens and improve healthcare interactions, while at the same time optimizing existing systems and effectively allocating resources. What do you want to accomplish for your beneficiaries, and what will get you there? 

• Prioritize these outcomes. Which will deliver the highest impact? Which are the most attainable? Prioritizing desired outcomes will help inform your roadmap, reduce risk and keep you driving toward your goals. 

• Evaluate options to determine the best approach for your enterprise. What business areas are your biggest challenges, and how could new technologies support progress? What is your desired timeline and budget for achieving outcomes? 

Transforming for the Future

Modernizing current systems and processes is essential to the evolution and sustainability of state Medicaid programs and their ability to meet the needs of members today and in the future. Modernization is inevitable.

From the very outset, states will have the greatest success if they think of modernization not as a technology project, but as true, outcomes-based transformation. This will get you not only to your destination, but also set you up for continuous improvement over the long term.

For a more in-depth look at Medicaid modernization, read Gainwell’s white paper, Modernizing Medicaid: An Outcomes-Based Roadmap.