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Navigating Medicaid Modularity: A Phased Approach to Better Outcomes

A senior gentleman with glasses is seated beside a female physician. She dons eyeglasses, a white lab coat, and a stethoscope, as they discuss his medical records.We talk a lot about the need to modernize Medicaid systems, but why is it so important? To put it into perspective, consider the major airline snafu that took place during the recent holiday season, interrupting service for millions of travelers. The airline’s legacy system wasn’t equipped to handle the high volume of cancellations due to an extreme weather event.  

Modernizing Medicaid systems can help to prevent similar failures from occurring in the healthcare industry and interrupting vital services to recipients. States are taking a more proactive approach to modularity.  Read on for outcomes-based insights to help states plan, execute and sustain their modernization goals.  

It’s All in the Planning  

Every journey should start with a clear map to the destination, and the road to modularity is no different. The planning phase is perhaps the most critical, as it lays the foundation not only for a successful implementation, but also the long-term viability of the system. The following are key factors to consider prior to Day One.    

Document a clear understanding of program objectives. Look at the larger business case for modernization, such as improving overall program outcomes and reducing technical debt.  

  • Establish staffing, structure and governance. As states partner with one or more vendors to implement and integrate modules, having the adequate staffing infrastructure and project management program in place can help to clearly define the roles and responsibilities of all stakeholders.  

  • Analyze your enterprise architecture. Take the time to assess your as-is enterprise architecture and gain a clear vision of your to-be enterprise architecture. If business processes are outdated, now is the time to transform them. 

  • Plan the right sequence of modules. Maximize the value of modernization and reduce implementation risk by carefully planning the sequence of modules based on business values.  

  • Establish standards. Work closely with your roadmap and system integration (SI) vendors to define data exchange, security and network standards. Having these discussions in advance will save time and avoid problems during the implementation. 

  • Keep claims processing and financial functions together. Some functions simply work better together, such as electronic data interchange (EDI), claims processing and financial models.  

Executing on Your Objectives  

This is when everything begins to come together as intended through careful preparation; however, that isn't to say the planning is over. Successfully navigating the execution phase involves ensuring all the right people, tools and systems are working cohesively together toward the established outcomes. Here are some of the most critical areas to prioritize.   

  • Create an integrated master plan. Develop and execute a baseline plan that provides a view of all intermodular integration points. Conduct weekly meetings to discuss any risks or issues as well as mitigation plans. 

  • Use valuable enterprise collaboration tools. These basic tools, which can include change management and program management, will enable greater collaboration. It’s often best if these tools come from the state or your SI vendor.  

  • Develop an enterprise testing strategy. Modularity involves separating a working system into different pieces, which adds many potential failure points into the integration process. For this reason, a testing strategy is extremely important and should be developed as soon as you begin the implementation process. 

  • Take an incremental approach. Connecting only one or two modules to your existing MMIS at a time, rather than taking a big-bang approach, can extend the life of your MMIS and reduce implementation risks. 

  • Focus on user training. Educate users and stakeholders on modular systems early in the process. Their feedback after go-live will be most important in determining whether your implementation was successful.  

  • Plan a help desk strategy. Depending on the design of the new system, a state’s current help desk strategy may not work. Early in the process, seek clarity on any changes needed for the modular environment and document new operational procedures.  

  • Create a certification plan. New modules will need to go through a modular CMS certification process. During the execution phase, create and finalize a plan that includes all the tasks that need to be completed during this phase. 

Operating with Excellence  

Based on Gainwell’s experience with two states that went live in 2022, here are some lessons learned that can impact operations during and post-implementation.  

  • Be prepared for production issues. Align design, development, implementation and support personnel so that the support team knows how the system works and can help resolve problems. Document any issues as well as how the problem was resolved. 

  • Execute your CMS certification plan. Once the system is stabilized, identify stakeholders, including your SI vendor, to work with on outlining responsibilities for the plan. Complete this in the first six months of go-live.  

  • Look for operational efficiencies. Use tools such as automation and process improvement to increase efficiency, and let your vendor know of any areas of concern.  

  • Collaborate with your people. They will have the best ideas for optimization since they are using the business processes on a daily basis. They will know what needs to be done and how they can become more efficient.  

Modularity and modernization are our present and future in providing healthcare more efficiently and cost-effectively to Medicaid recipients. Implementing these suggestions can help states through their journey into continuous improvement.